Axillary Lymphatic Evaluation: A Solution to a Complex Problem

Annals of Surgical Oncology -     

The Impact of the New Kidney Allocation System on Prior Living Kidney Donors’ Access to Deceased Donor Kidney Transplants: An Early Look

This study investigated the early effects of the new kidney allocation system (KAS) on the access of prior living kidney donors (PLDs) to deceased donor kidney transplants. Using data from the Organ Procurement and Transplantation Network, we compared prevalent and incident cohorts of PLDs in the 1‐year periods before and after KAS implementation (pre‐KAS group: December 4, 2013, to December 3, 2014, n = 50 [newly listed PLDs]; post‐KAS group: December 4, 2014, to December 3, 2015, n = 39). We assessed transplant rates per active patient‐year, waiting times, and Kidney Donor Profile Index (KDPI) of transplanted kidneys. Transplant rates were not statistically different before and after KAS implementation for either prevalent (2.37 vs. 2.29, relative risk [RR] 0.96; 95% confidence interval [CI] 0.62–1.49) or incident (4.76 vs. 4.36, RR 0.92; 95% CI 0.53–1.60) candidates. Median waiting time (MWT) to deceased donor kidney transplant for prevalent PLDs in the post‐KAS cohort was 102.6 days compared with 82.3 days in the pre‐KAS cohort (p = 0.98). The median KDPI for PLD recipients was 31% with KAS versus 23% before KAS (p = 0.02). Despite a sharp decrease in the MWT for highly prioritized candidates with calculated panel reactive antibodies of 98–100% (from >7000 to 1164 days), PLDs still had much shorter waiting times (MWT 102.6 days). The new system continues to provide quick access to high‐quality organs for PLDs.     

The Advantage of Multiple Listing Continues in the Kidney Allocation System Era

BackgroundTransplant candidates can be listed at multiple transplant centers to increase the probability of receiving an organ. We evaluated the association between multilisting (ML) status and access to a deceased donor kidney transplant (DDKT) to determine if ML provides a long-term advantage regarding wait-list mortality and recipient outcomes.Materials and MethodsCandidates between January 2010 and October 2017 were identified as either singly or multiply listed using Organ Procurement and Transplantation Network data and cohorts before and after implementation of the Kidney Allocation System (KAS). Cross-sectional logistic regression was used to assess relationships between candidate factors and ML prevalence (5.4%).ResultsFactors associated with ML pre-KAS included having blood type B (reference, type O; odds ratio [OR], 1.20; P < .001), having private insurance (OR, 1.5; P < .001), wait time (OR, 1.28; P < .001), and increasing calculated panel-reactive antibody (cPRA) (reference, cPRA 0-100; OR for cPRA 80-98, 2.83; OR for cPRA 99, 3.47; OR for cPRA 100, 5.18; P < .001). Transplant rates were double for multilisted vs singly listed recipients (adjusted hazard ratio [aHR], 2.16; P < .001). Extra–donor service area ML candidates received transplants 2.5 years quicker than single-listing (SL) candidates, conferring a 42% wait-list advantage. Recipient death (aHR, 0.94; P = .122) and graft failure (aHR, 0.91; P = .006) rates were also lower for ML recipients.ConclusionsIn the KAS era, ML continues to increase the likelihood of receiving a DDKT and lower the incidence of wait-list mortality, and it confers a survival advantages over SL.     

The Kidney Allocation Score: Methodological Problems, Moral Concerns and Unintended Consequences

The growing disparity between the demand for and supply of kidneys for transplantation has generated interest in alternative systems of allocating kidneys from deceased donors. This personal viewpoint focuses attention on the Kidney Allocation Score (KAS) proposal promulgated by the UNOS/OPTN Kidney Committee. I identify several methodological and moral flaws in the proposed system, concluding that any iteration of the KAS proposal should be met with more skepticism than sanguinity.     

Editorial Commentary: The Hip Capsule Is No Longer a Problem to Overcome,It Is Part of the Solution

Hip capsular management is still controversial. Improvements in patient-reported outcomes have been reported with repair of an interportal capsulotomy, which is used for hip access. In addition, a lower rate of conversion to hip replacement after capsular closure has been reported. Central compartment–first arthroscopy violates the capsule at the start of the procedure, so a capsular procedure is being performed at the start of any hip arthroscopy. Even in the absence of hyperlaxity or mild dysplasia, capsular repair should be considered to optimize patient outcomes.     

Renin Angiotensin System Blockade in Kidney Transplantation: A Systematic Review of the Evidence

ACE-inhibitors and angiotensin receptor blockers (ARB) slow the progression of renal disease in non-transplant patients. A systematic review of randomized trials (n = 21 trials with 1549 patients) was conducted to determine the effect of ACE-inhibitor or ARB use following kidney transplantation. With a median follow-up of 27 months, ACE-inhibitor or ARB use was associated with a significant decrease in glomerular filtration rate (-5.8 mL/min; 95% CI -10.6 to -0.99). ACE-inhibitor or ARB use resulted in a lower hematocrit (-3.5%; 95% CI -6.1 to -0.95), reduction in proteinuria (-0.47 gm/d; 95% CI -0.86 to -0.08) but no change in the serum potassium (0.18 mmol/L; 95% CI -0.03 to 0.40). ACE-inhibitor or ARB use results in clinically important reductions in proteinuria, hematocrit and glomerular filtration rate in renal transplant recipients, but there are insufficient data to determine the effect on patient or graft survival. Randomized trials of sufficient power and duration that examine these hard outcomes should be conducted. Until such trials are completed, this study provides quantitative estimates of the risks and benefits of ACE-inhibitor or ARB use that can be used by clinicians considering prescribing these medications to kidney transplant recipients or to researchers designing future trials.     

Surveillance of Human Papilloma Virus Infection and Cervical Cancer in Kidney Transplant Recipients: Preliminary Data

Introduction

Development of cancer after transplantation has rapidly became one of the leading causes of death in kidney transplant recipients with functioning grafts. Anogenital malignant neoplasms may occur with a 14-fold increased incidence, and human papilloma virus (HPV) infection has been recently identified as the leading cause of cervical carcinoma. We report the preliminary findings of a prospective study that evaluated the incidence of HPV infection and cervical carcinoma in a population of kidney transplant recipients.

Patients and Methods

The study included 35 female recipients of a deceased donor kidney with at least 6 months of follow-up. All patients underwent a cervicovaginal brushing, an HPV DNA test, and a Papanicolaou test.

Results

Twenty-two patients (62.8%) were positive for HPV DNA. Thirteen of 22 HPV DNA-positive recipients (59%) demonstrated a high-risk HPV genotype. No cytologic anomalies were detected in Papanicolaou smears.

Conclusions

These preliminary data demonstrated a high incidence of HPV infection in renal transplant recipients. Most of our recipients exhibited a high-risk HPV genotype, which suggests higher aggressiveness of such infection in immunosuppressed patients. The HPV test is useful to monitor patients at higher risk of anogenital malignant neoplasms by identifying the cytologic anomalies at an earlier stage. This ongoing study will investigate the rate of progression of HPV infection and the clinical patterns of HPV-positive cytologic anomalies in renal transplant recipients.