Second Kidney Transplant Outcomes in Dialysis Dependent Recipients by Induction Type in the United States

BackgroundWe examined the association between induction type for a second kidney transplant in dialysis-dependent recipients and the long-term outcomes.MethodsUsing the Scientific Registry of Transplant Recipients, we identified all second kidney transplant recipients who returned to dialysis before re-transplantation. Exclusion criteria included: missing, unusual, or no-induction regimens, maintenance regimens other than tacrolimus and mycophenolate, and positive crossmatch status. We grouped recipients by induction type into 3 groups: the anti-thymocyte group (N = 9899), the alemtuzumab group (N = 1982), and the interleukin 2 receptor antagonist group (N = 1904). We analyzed recipient and death-censored graft survival (DCGS) using the Kaplan-Meier survival function with follow-up censored at 10 years post-transplant. We used Cox proportional hazard models to examine the association between induction and the outcomes of interest. To account for the center-specific effect, we included the center as a random effect. We adjusted the models for the pertinent recipient and organ variables.ResultsIn the Kaplan-Meier analyses, induction type did not alter recipient survival (log-rank P = .419) or DCGS (log-rank P = .146). Similarly, in the adjusted models, induction type was not a predictor of recipient or graft survival. Live-donor kidneys were associated with better recipient survival (HR 0.73, 95% CI [0.65, 0.83], P < .001) and graft survival (HR 0.72, 95% CI [0.64, 0.82], P < .001). Publicly insured recipients had worse recipient and allograft outcomes.ConclusionIn this large cohort of average immunologic-risk dialysis-dependent second kidney transplant recipients, who were discharged on tacrolimus and mycophenolate maintenance, induction type did not influence the long-term outcomes of recipient or graft survival. Live-donor kidneys improved recipient and graft survival.     

Kidney Transplant Outcomes in Indigenous People of the Northern Great Plains of the United States

BackgroundIndigenous people experience higher rates of end-stage renal disease as well as negative predictive factors that undermine kidney transplantation (KT) success. Despite these inequalities, data suggest that short-term outcomes are comparable to those of other groups, but few studies have examined this effect in the Northern Great Plains (NGP) region.MethodsWe performed a retrospective database review to determine outcomes of KT in Indigenous people of the NGP. White and Indigenous people receiving a KT between 2000 and 2018 at a single center were examined.ResultsA total of 622 KT recipients were included (117 Indigenous and 505 White). Indigenous patients were more likely to smoke, have diabetes, have higher immunologic risk, receive fewer living donor kidneys, and have longer waitlist times. In the 5 years after KT there were no significant differences in renal function, rejection events, cancer, graft failure, or patient survival. At 10 years posttransplant, Indigenous patients had twice the all-cause graft failure (odds ratio = 2.06; 95% confidence interval, 1.25–3.39) and half the survival rate (odds ratio = 0.47; 95% confidence interval, 0.29–0.76); however, this effect was not maintained once the effects of race, sex, smoking status, diabetes, preemptive transplant, high panel reactive antibody status, and transplant type were adjusted for.ConclusionsKT outcomes in Indigenous patients in the NGP region are similar to those of White patients 5 years posttransplant, with differences emerging at 10 years that could be diminished with greater emphasis on correcting modifiable risk factors.     

Outcomes of Adult Dual Kidney Transplants by KDRI in the United States

UNOS guidelines provide inadequate discriminatory criteria for kidneys that should be transplanted as single (SKT) versus dual (DKT). We evaluated the utility of the kidney donor risk index (KDRI) to define kidneys with better outcomes when transplanted as dual. Using SRTR data from 1995 to 2010 of de novo KTX recipients of adult deceased‐donor kidneys, we examined outcomes of SKT and DKT stratified by KDRI group ≤1.4 (n = 49 294), 1.41–1.8 (n = 15 674), 1.81–2.2 (n = 6523) and >2.2 (n = 2791). DKT of kidneys with KDRI >2.2 was associated with significantly better overall graft survival [adjusted hazard ratio (aHR) 0.83, 95% confidence interval (CI) 0.72–0.96] compared to single kidneys with KDRI >2.2. DKT was associated with significantly decreased odds of delayed graft function (top 2 KDRI categories) and significantly decreased odds of 1‐year serum creatinine level >2 mg/dL (top 3 KDRI categories). Among SKT and DKT from KDRI >2.2 there were 16.1 and 13.9 graft losses per 100 patient follow‐up years, respectively. KDRI >2.2 is a useful discriminatory cut‐off for the determination of graft survival benefit with the use of DKT; however, the benefit of increased graft years was less than half of single kidneys from donors in the same KDRI range.     

Induction Type and Outcomes in HLA-DR Mismatch Kidney Transplantation

BackgroundIn kidney transplantation, donor recipient human leukocyte antigen (HLA)-DR mismatch signals high immunologic risk and portends inferior outcomes. We compared the impacts of depleting vs non-depleting antibody induction on the outcomes in kidney transplant recipients (KTRs) at different levels of HLA-DR mismatches.MethodsUsing the Organ Procurement and Transplantation Network/United Network for Organ Sharing database, we identified adult KTRs from 2001 to 2015 who received induction therapy with either depleting (thymoglobulin/alemtuzumab) or non-depleting (basiliximab/daclizumab) antibody and were discharged on calcineurin inhibitor/mycophenolic acid maintenance. Patients were then stratified by the number of donor-recipient HLA-DR mismatches (0, 1, 2) in both living donor (LD) and deceased donor (DD) KTRs. Under each HLA-DR mismatch category, long-term outcomes were compared for depleting vs non-depleting induction using a Cox model.ResultsA total of 63,821 LD (HLA-DR mismatches: 0, n = 6945 [depleting = 4409, non-depleting = 2536]; 1, n = 19,557 [depleting = 13,558, non-depleting = 6019]; and 2, n = 10,727 [depleting = 7694, non-depleting = 3033]) and 64,922 DD (HLA-DR mismatches: 0, n = 13,915 [depleting = 10,124, non-depleting = 3791]; 1, n = 27,994 [depleting = 20,454, non-depleting = 7540]; and 2, n = 23,013 [depleting = 16,908, non-depleting = 6105]) KTRs were included in the analysis. Adjusted patient death risk was significantly lower in the depleting vs non-depleting antibody induction group among DD kidney recipients (hazard ratio 0.90, 95% CI 0.85–0.96, P = .001) and trended lower among LD kidney recipients (HR 0.88, 95% 0.79–1.01, P = .05) with 2 HLA-DR mismatches.DiscussionOur study found a patient survival benefit associated with the use of perioperative induction with depleting when compared to non-depleting antibody in KTRs with 2 HLA-DR mismatches and maintained on a calcineurin inhibitor/mycophenolic acid regimen.     

Racial and Ethnic Differences in Pediatric Access to Preemptive Kidney Transplantation in the United States

Preemptive kidney transplantation is the optimal treatment for pediatric end stage renal disease patients to avoid increased morbidity and mortality associated with dialysis. It is unknown how race/ethnicity and poverty influence preemptive transplant access in pediatric. We examined the incidence of living donor or deceased donor preemptive transplantation among all black, white, and Hispanic children (<18 years) in the United States Renal Data System from 2000 to 2009. Adjusted risk ratios for preemptive transplant were calculated using multivariable‐adjusted models and examined across health insurance and neighborhood poverty levels. Among 8,053 patients, 1117 (13.9%) received a preemptive transplant (66.9% from LD, 33.1% from DD). In multivariable analyses, there were significant racial/ethnic disparities in access to LD preemptive transplant where blacks were 66% (RR = 0.34; 95% CI: 0.28–0.43) and Hispanics 52% (RR = 0.48; 95% CI: 0.35–0.67) less likely to receive a LD preemptive transplant versus whites. Blacks were 22% less likely to receive a DD preemptive transplant versus whites (RR = 0.78, 95% CI: 0.57–1.05), although results were not statistically significant. Future efforts to promote equity in preemptive transplant should address the critical issues of improving access to pre‐ESRD nephrology care and overcoming barriers in living donation, including obstacles partially driven by poverty.     

Risk of Renal Cell Carcinoma Among Kidney Transplant Recipients in the United States

Renal cell carcinoma (RCC) is a common malignancy following kidney transplantation. We describe RCC risk and examine RCC risk factors among US kidney recipients (1987–2010). The Transplant Cancer Match Study links the US transplant registry with 15 cancer registries. Standardized incidence ratios (SIRs) were used to compare RCC risk (overall and for clear cell [ccRCC] and papillary subtypes) to the general population. Associations with risk factors were assessed using Cox models. We identified 683 RCCs among 116 208 kidney recipients. RCC risk was substantially elevated compared with the general population (SIR 5.68, 95% confidence interval 5.27–6.13), especially for papillary RCC (SIR 13.3 versus 3.98 for ccRCC). Among kidney recipients, RCC risk was significantly elevated for blacks compared to whites (hazard ratio [HR] 1.50) and lower in females than males (HR 0.56). RCC risk increased with prolonged dialysis preceding transplantation (p‐trend < 0.0001). Risk was variably associated for RCC subtypes with some medical conditions that were indications for transplantation: ccRCC risk was reduced with polycystic kidney disease (HR 0.54), and papillary RCC was increased with hypertensive nephrosclerosis (HR 2.02) and vascular diseases (HR 1.86). In conclusion, kidney recipients experience substantially elevated risk of RCC, especially for papillary RCC, and multiple factors contribute to these cancers.     

Outcomes in Obese Kidney Transplant Recipients

BackgroundKidney transplantation (KT) in obese patients is controversial. The present study aimed to evaluate patient and graft survival and post-transplantation complications between obese and nonobese recipients.MethodsPatients (n = 3,054) receiving a KT from 1998 to 2008 were divided according to body mass index (BMI) into 3 groups for analysis: group I: BMI <30 kg/m² (nonobese); group II: ≥30–34.9 kg/m² (class I obese); and group III: ≥35 kg/m² (class II and III obese).ResultsMean BMIs were: group I (n = 2,822): 22.6 ± 3.3 kg/m²; group II (n = 185): 31.9 ± 1.3 kg/m²; and group III (n = 47): 36.8 ± 1.7 kg/m². There were no differences among the 3 groups in patient demographic variables regarding race, sex, or organ source. One-year (I, 98%; II, 98%; III, 95%) and 5-year (I, 90%; II, 92%; III, 89%) patient survival rates were similar among groups. Graft survival rates at 1 year were 96% for groups I and II and 91.5% for group III. Five-year graft survivals were: I, 81%; II, 96%; and III, 79%. The most common cause of graft loss was death, and the main cause of death was infection in all groups. Obese patients were more likely to experience wound dehiscence (I, 1.9%; II, 7.6%; III, 19.1%; P < .001), develop new-onset diabetes after transplantation (NODAT; I, 16.2%; II, 27%; III, 36%; P < .001), and have a prolonged length of hospital stay (I, 11.3 ± 11.4 d; II, 14.5 ± 14.3 d; III, 15.9 ± 16.7 d; P < .001).ConclusionsObese recipients demonstrated outcomes similar to nonobese patients regarding patient and graft survival. However, they had higher rates of prolonged length of hospital stay, wound dehiscence, and NODAT.     

The Association of Center Performance Evaluations and Kidney Transplant Volume in the United States

Report cards evaluating transplant center performance have received significant attention in recent years corresponding with the Centers for Medicare and Medicaid Services issue of the 2007 Conditions of Participation. Our primary aim was to evaluate the association of report card evaluations with transplant center volume. We utilized data from the Scientific Registry of Transplant Recipients (SRTR) along with six consecutive program‐specific reports from January 2007 to July 2009 for adult kidney transplant centers. Among 203 centers, 46 (23%) were low performing (LP) with statistically significantly lower than expected 1‐year graft or patient survival at least once during the study period. Among LP centers, there was a mean decline in transplant volume of 22.4 cases compared to a mean increase of 7.8 transplants among other centers (p = 0.001). Changes in volume between LP and other centers were significant for living, standard and expanded criteria deceased donor (ECD) transplants. LPs had a reduction in use of donors with extended cold ischemia time (p = 0.04) and private pay recipients (p = 0.03). Centers without low performance evaluations were more likely to increase the proportion of overall transplants that were ECDs relative to other centers (p = 0.04). Findings indicate a significant association between reduced kidney transplant volume and low performance report card evaluations.     

Induction Immunosuppression and Clinical Outcomes in Kidney Transplant Recipients Infected With Human Immunodeficiency Virus

There is an increased risk of acute rejection (AR) in human immunodeficiency virus–positive (HIV+) kidney transplant (KT) recipients. Induction immunosuppression is standard of care for those at high risk of AR; however, use in HIV+ patients is controversial, given fears of increased infection rates. We sought to compare clinical outcomes between HIV+ KT recipients who were treated with (i) anti–thymocyte globulin (ATG), (ii) IL‐2 receptor blocker, and (iii) no induction. We studied 830 HIV+ KT recipients between 2000 and 2014, as captured in the Scientific Registry of Transplant Recipients, and compared rates of delayed graft function (DGF), AR, graft loss and death. Infections and hospitalizations were ascertained by International Classification of Diseases, Ninth Revision codes in a subset of 308 patients with Medicare. Compared with no induction, neither induction agent was associated with an increased risk of infection (weighted hazard ratio [wHR] 0.80, 95% confidence interval [CI] 0.55–1.18). HIV+ recipients who received induction spent fewer days in the hospital (weighted relative risk [wRR] 0.70, 95% CI 0.52–0.95), had lower rates of DGF (wRR 0.66, 95% CI 0.51–0.84), less graft loss (wHR 0.47, 95% CI 0.24–0.89) and a trend toward lower mortality (wHR 0.60, 95% CI 0.24–1.28). Those who received induction with ATG had lower rates of AR (wRR 0.59, 95% CI 0.35–0.99). Induction in HIV+ KT recipients was not associated with increased infections; in fact, those receiving ATG, the most potent agent, had the lowest rates. In light of the high risk of AR in this population, induction therapy should be strongly considered.     

Pregnancy Outcomes for Kidney Transplant Recipients

Pregnancy outcomes in a transplant population have not been well documented. Data from the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) and the National Perinatal Epidemiology and Statistics Unit (NPESU) were analyzed. We described pregnancy outcomes within the transplant population and compared these to outcomes for the general population. Six hundred ninety‐two pregnancies in 447 transplant recipients were reported between 1971 and 2010 (ANZDATA); a corresponding 5 269 645 pregnancies were reported nationally in Australia between 1991 and 2010 (NPESU). At pregnancy transplant mothers had a median age of 31 years (interquartile range [IQR]: 27, 34), a median creatinine of 106 µmol/L (IQR: 88, 1103 µmol/L) and a functioning transplant for a median of 5 years (IQR: 3, 9). The mean gestational age at birth was 35 ± 5 weeks in transplant recipients, significantly shorter than the national average of 39 weeks (p < 0.0001). Mean live birth weight for transplant recipients was 873 g lower than the national average (2485 ± 783 g vs. 3358 ± 2 g); a significant difference remained after controlling for gestational age. There was lower perinatal survival rate in babies born to transplant recipients, 94% compared with 99% nationally (p < 0.001). Although transplant pregnancies are generally successful, outcomes differ from the general population, indicating these remain high‐risk pregnancies despite good allograft function.     

Early Referral,Living Donation,and Preemptive Kidney Transplant

BackgroundPreemptive kidney transplant (PKT) is recognized as the most beneficial and cost-effective form of renal replacement therapy among patients with end-stage renal disease. Despite optimal outcomes and improved quality of life associated with PKT, its use as a first renal replacement therapy remains low among patients with end-stage renal disease. The goal of this retrospective cohort study was to compare, among adult kidney transplant recipients, characteristics across PKT status.MethodsWe compared the characteristics of patients who did and did not have a PKT over 5 years, from 2010 to 2014, using the electronic health records of Kaiser Permanente Mid-Atlantic States.ResultsA total of 233 patients received a kidney-alone transplant, and, of these, 44 patients (19%) were PKT and 189 patients (81%) were non-PKT. Of the patients in the PKT group, 43% received a kidney from a deceased donor. PKT recipients were more often White, had polycystic kidney disease or glomerulonephritis, received a living donor organ, and were transplanted at certain transplant centers. Estimated glomerular filtration rate on listing for those who received a deceased donor transplant was higher in PKT than non-PKT patients listed pre-dialysis.ConclusionsPKT was associated with having a living kidney donor and with having a higher estimated glomerular filtration rate at listing for deceased donor recipients.     

Outcomes Following Colorectal Resection in Kidney Transplant Recipients

Background

Kidney transplant recipients (KTR) are at increased risk of requiring colorectal resection compared to the general population. Given the need for lifelong immunosuppression and the physiologic impact of years of renal replacement, we hypothesized that colorectal resection may be riskier for this unique population.

Methods

We investigated the differences in mortality, morbidity, length of stay (LOS), and cost between 2410 KTR and 1,433,437 non-KTR undergoing colorectal resection at both transplant and non-transplant centers using the National Inpatient Sample between 2000 and 2013, adjusting for patient and hospital level factors.

Results

In hospital, mortality was higher for KTR in comparison to non-KTR (11.1 vs 4.3%, p?<?0.001; adjusted odds ratio [aOR] _2.683.59_4.81) as were overall complications (38.5 vs 31.5%, p?=?0.001; aOR _1.081.30_1.56). LOS was significantly longer (10 vs 7 days, p?<?0.001; ratio _1.421.53_1.65) and cost was significantly greater ($23,056 vs $14,139, p?<?0.001; ratio _1.421.54_1.63) for KTR compared to non-KTR. While LOS was longer for KTR undergoing resection at transplant centers compared to non-transplant centers (aOR 1.68 vs 1.53, p?=?0.03), there were no statistically significant differences in mortality, overall morbidity, or cost by center type.

Conclusions

KTR have higher mortality, higher incidence of overall complications, longer LOS, and higher cost than non-KTR following colorectal resection, regardless of center type. Physicians should consider these elevated risks when planning for surgery in the KTR population and counsel patients accordingly.

     

Living Donor Age and Kidney Transplant Outcomes

We assessed the relationship between living donor (LD) age and kidney survival in 1063 adults transplanted between 1980 and 2007. Increasing LD age was associated with lower kidney function (GFR) before and after transplantation and loss of GFR beyond 1 year. Increasing LD age was also associated with low‐moderate proteinuria posttransplant (151–1500 mg/day, p < 0.0001). By univariate analysis, reduced graft survival related to lower GFR at 1 year [HR = 0.925 (0.906–0.944), p < 0.0001], proteinuria [HR = 1.481 (1.333–1.646), p < 0.0001] and increasing LD age [HR = 1.271 (1.219–1.326), p = 0.001]. The impact of LD age on graft survival was noted particularly >4 years posttransplant and was modified by recipient age. Thus, compared to a kidney graft that was within 5 years of the recipient age, younger kidneys had a survival advantage [HR = 0.600 (0.380–0.949), p = 0.029] while older kidneys had a survival disadvantage [HR = 2.217 (1.507–3.261), p < 0.0001]. However, this effect was seen only in recipients <50 years old. By multivariate analysis, the relationship between LD age and graft survival was independent of GFR but related to proteinuria. In conclusion, LD age is an important determinant of long‐term graft survival, particularly in younger recipients. Older kidneys with reduced survival are identifiable by the development of proteinuria posttransplant.     

Donor Ethnicity and Kidney Transplant Outcomes in African Americans

BackgroundTransplantation of African American (AA) compared to non-AA donor kidneys is generally associated with inferior outcomes. It is unclear whether enhanced genetic risk associated with AA donor kidneys would be counterbalanced by favorable immunologic matching when AA donor kidneys are transplanted into AA recipients. We aimed to compare the outcomes of AA vs non-AA deceased-donor kidneys (DDKs) stratified by kidney donor profile index (KDPI) that were transplanted into AA recipients.MethodsUsing the Organ Procurement and Transplant Network/United Network for Organ Sharing database, we identified AA DDK recipients from 2000 to 2015 who received peri-operative induction followed by calcineurin inhibitor/mycophenolate mofetil maintenance. These patients were divided into 4 KDPI groups (0%-20%, 21%-50%, 51%-85%, and 86%-100%). Adjusted long-term graft and patient outcomes were compared between AA recipients of kidneys from AA vs non-AA donors in each KDPI category using a multivariable Cox model.ResultsAmong a total of 17,516 AA DDK transplant recipients, 3303 were in KDPI 0%-20% (AA donor = 239; non-AA donor = 3064), 5821 in KDPI 21%-50% (AA donor = 1414; non-AA donor = 4407), 6364 in KDPI 51%-85% (AA donor = 1619; non-AA donor = 4745), and 2028 in KDPI 86%-100% (AA donor = 932; non-AA donor = 1096) groups. Adjusted overall graft, death-censored graft, and patient survival were similar between AA recipients of AA vs non-AA donor kidneys across all KDPI groups.DiscussionOur study showed similar outcomes for transplanting AA vs non-AA deceased-donor kidneys into AA recipients despite the generally observed inferior outcomes associated with AA donor kidney transplantation.     

Belatacept Conversion Protocols and Outcomes in Kidney Transplant Recipients

BackgroundConversion from calcineurin inhibitor (CNI)-based to belatacept-based immunosuppression has become common; however, numerous protocols have emerged in lieu of a standardized protocol. The purpose of this study was to characterize belatacept conversion protocols from multiple centers and observe outcomes.MethodsThis was a retrospective study that included Kaiser Permanente Southern California members. The primary outcome was rejection 6 months after conversion and secondary outcomes included change in serum creatinine and graft loss.ResultsSeventy-eight patients were included. Thirteen distinct protocols were identified from 8 different transplant centers. Protocols varied by initial dose, induction schedule, and CNI taper. The observed rate of rejection was 6%. There was a trend toward an association of rejection with lower tacrolimus exposure at the time of conversion and lower mycophenolic acid dosing postconversion. Graft survival was 88% and patient survival was 94%. There was a significant improvement in creatinine after conversion. Those with early conversions and creatinine >2.0 mg/dL at the time of conversion had the best response.ConclusionsA large variety of belatacept conversion protocols were identified. Protocols were defined by the initial dose, induction regimen, and CNI taper. Rejection rates were low and may be influenced by exposure to maintenance immunosuppression during and after conversion. Most patients showed stabilization and improvement in creatinine postconversion, with the largest effect in those with an early conversion and serum creatinine >2.0 mg/dL.     

Assessment of the Utility of Kidney Histology as a Basis for Discarding Organs in the United States: A Comparison of International Transplant Practices and Outcomes

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Kidney Transplant Outcomes for Prior Living Organ Donors

The Organ Procurement and Transplantation Network gives priority in kidney allocation to prior live organ donors who require a kidney transplant. In this study, we analyzed the effect of this policy on facilitating access to transplantation for prior donors who were wait-listed for kidney transplantation in the United States. Using 1:1 propensity score–matching methods, we assembled two matched cohorts. The first cohort consisted of prior organ donors and matched nondonors who were wait-listed during the years 1996–2010. The second cohort consisted of prior organ donors and matched nondonors who underwent deceased donor kidney transplantation. During the study period, there were 385,498 listings for kidney transplantation, 252 of which were prior donors. Most prior donors required dialysis by the time of listing (64% versus 69% among matched candidates; P=0.24). Compared with matched nondonors, prior donors had a higher rate of deceased donor transplant (85% versus 33%; P<0.001) and a lower median time to transplantation (145 versus 1607 days; P<0.001). Prior donors received higher-quality allografts (median kidney donor risk index 0.67 versus 0.90 for nondonors; P<0.001) and experienced lower post-transplant mortality (hazard ratio, 0.19; 95% confidence interval, 0.08 to 0.46; P<0.001) than matched nondonors. In conclusion, these data suggest that prior organ donors experience brief waiting time for kidney transplant and receive excellent-quality kidneys, but most need pretransplant dialysis. Individuals who are considering live organ donation should be provided with this information because this allocation priority will remain in place under the new US kidney allocation system.     

Pregnancy and Maternal Outcomes Among Kidney Transplant Recipients

Fertility rates, pregnancy, and maternal outcomes are not well described among women with a functioning kidney transplant. Using data from the Australian and New Zealand Dialysis and Transplant Registry, we analyzed 40 yr of pregnancy-related outcomes for transplant recipients. This analysis included 444 live births reported from 577 pregnancies; the absolute but not relative fertility rate fell during these four decades. Of pregnancies achieved, 97% were beyond the first year after transplantation. The mean age at the time of pregnancy was 29 ± 5 yr. Compared with previous decades, the mean age during the last decade increased significantly to 32 yr (P < 0.001). The proportion of live births doubled during the last decade, whereas surgical terminations declined (P < 0.001). The fertility rate (or live-birth rate) for this cohort of women was 0.19 (95% confidence interval 0.17 to 0.21) relative to the Australian background population. We also matched 120 parous with 120 nulliparous women by year of transplantation, duration of transplant, age at transplantation ±5 yr, and predelivery creatinine for parous women or serum creatinine for nulliparous women; a first live birth was not associated with a poorer 20-yr graft or patient survival. Maternal complications included preeclampsia in 27% and gestational diabetes in 1%. Taken together, these data confirm that a live birth in women with a functioning graft does not have an adverse impact on graft and patient survival.One of the many perceived benefits of kidney transplantation has been restoration of pituitary-ovarian function and fertility in women of reproductive age. Prenatal advice for women with a functioning kidney transplant has been primarily based on data derived from observational research,^1–13 and the reported live-birth rates achieved in such women range from 43.2¹⁴ to 82%.¹⁵Although an increased pregnancy event number has been reported for women with a functioning kidney transplant,¹⁶ little is actually known about “pregnancy rate changes” during the past 40 yr. More importantly, long-term graft and maternal survival analyses, referred to when advising women who have undergone transplantation and are considering a pregnancy, have been mostly performed without adequate matching,¹² or, alternatively, matching has been used but outcomes followed up for only brief intervals^14,17,18 and in small cohorts.^19–22 Published graft matching studies to date suggest no adverse impact 10 yr after a live birth.¹⁴In most instances, pregnancies in women with a kidney graft have been encouraged. Historically, renal function,^8,15,17,18 baseline proteinuria,²³ intercurrent hypertension,^1,24 and time from transplantation^{1,3,5,8,14,15,18,24,25} have been used to predict adverse event risks to the mother, kidney, and offspring. To this are added the often unquantifiable inherent risks for genetically transmitted diseases or the problems associated with prematurity.^26,27 More recently, epidemiologic evidence suggests low birth weight may be associated with the development of hypertension,²⁸ cardiovascular disease,²⁹ insulin resistance,³⁰ and end-stage renal failure.³¹ Moreover, low birth weight is associated with an increased risk for hypertension, independent of genetic and shared environmental factors.³²Series published to date have not captured all pregnancy events or their outcomes. Limitations of some of the published studies include short duration of follow-up and studies with no adequate or long-term matching for decade and renal function.We examined fertility rates, pregnancy rates, and pregnancy outcomes over 40 yr in an at-risk population, defined as women who were aged between 15 and 49 and had a functioning kidney transplant, using ANZDATA registry data. In addition, maternal and graft outcomes were analyzed, and, uniquely, a matched cohort analysis of 120 nulliparous and 120 parous women who had undergone transplantation enabled analysis of outcomes at 20 yr.     

Cancer after Kidney Transplantation in the United States

Previous reports of cancer after kidney transplantation have been limited by small numbers of patients in single-center studies and incomplete ascertainment of cases in large registries. We examined rates of malignancies among first-time recipients of deceased or living donor kidney transplantations in 1995-2001 (n = 35 765) using Medicare billing claims. For most common tumors, e.g. colon, lung, prostate, stomach, esophagus, pancreas, ovary and breast, cancer rates were roughly twofold higher after kidney transplantation compared with the general population. Melanoma, leukemia, hepatobiliary tumors, cervical and vulvovaginal tumors were each approximately fivefold more common. Testicular and bladder cancers were increased approximately threefold, while kidney cancer was approximately 15-fold more common. Kaposi's sarcoma, non-Hodgkin's lymphomas, and nonmelanoma skin cancers were more than 20-fold increased than in the general population. Compared with patients on the waiting list, several tumors were more common after transplantation (p < 0.01): nonmelanoma skin cancers (2.6-fold), melanoma (2.2-fold), Kaposi's sarcoma (9.0-fold), non-Hodgkin's lymphoma (3.3-fold), cancer of the mouth (2.2-fold), and cancer of the kidney (39% higher). The rates for most malignancies are higher after kidney transplantation compared with the general population. Cancer should continue to be a major focus of prevention in kidney transplantation.