Evidence-based practice: Guidance for using everolimus in combination with low-exposure calcineurin inhibitors as initial immunosuppression in kidney transplant patients.

The mammalian target of rapamycin (mTOR) inhibitor, everolimus, in combination with reduced-exposure calcineurin inhibitor (CNI), has been demonstrated in clinical trials to have comparable efficacy in low-to-moderate immunological risk kidney transplant recipients to the Standard of Care, mycophenolic acid (MPA) in combination with standard-exposure CNI. Current treatment guidelines consider mTOR inhibitors to be a second-line therapy in the majority of cases; however, given that everolimus-based regimens are associated with a reduced rate of viral infections after transplantation, their wider use could have great benefits for kidney transplant patients. In this evidence-based practice guideline, we consider the de novo use of everolimus in kidney transplant recipients.

Clinical utility of C3d binding donor-specific anti-human leukocyte antigen antibody detection by single antigen beads after kidney transplantation-a retrospective study.

Development of donor-specific antibodies (DSA) after renal transplantation is known to be associated with worse graft survival, yet determining which specificities in which recipients are the most deleterious remains under investigation. This study evaluated the relationship of the complement binding capacity of post-transplant de novo anti-human leukocyte antigen (HLA) antibodies with subsequent clinical outcome. Stored sera from 265 recipients previously identified as having de novo DSA were retested for DSA and their C3d binding capacity using Luminex-based solid-phase assays.

Establishing patient-specific criteria for selecting the optimal upper extremity vascular access procedure.

Objective: The Kidney Disease Outcome Quality Initiative and Fistula First Breakthrough Initiative call for the indiscriminate creation of arteriovenous fistulas (AVFs) over arteriovenous grafts (AVGs) without providing patient-specific criteria for vascular access selection. Although the U.S.

Evaluation of Flagging Criteria of United States Kidney Transplant Center Performance: How to Best Define Outliers?

Background: Scientific Registry of Transplant Recipients report cards of US organ transplant center performance are publicly available and used for quality oversight. Low center performance (LP) evaluations are associated with changes in practice including reduced transplant rates and increased waitlist removals. In 2014, Scientific Registry of Transplant Recipients implemented new Bayesian methodology to evaluate performance which was not adopted by Center for Medicare and Medicaid Services (CMS).

High mortality in diabetic recipients of high KDPI deceased donor kidneys.

Background: Deceased donor (DD) kidney quality is determined by calculating the Kidney Donor Profile Index (KDPI). Optimizing high KDPI (≥85%) DD transplant outcome is challenging. This retrospective study was performed to review our high KDPI DD transplant results to identify clinical practices that can improve future outcomes.

Preservation solutions used during abdominal transplantation: Current status and outcomes.

Organ preservation remains an important contributing factor to graft and patient outcomes. During donor organ procurement and transportation, cellular injury is mitigated through the use of preservation solutions in conjunction with hypothermia. Various preservation solutions and protocols exist with widespread variability among transplant centers.

Early immunosuppression treatment correlates with later de novo donor-specific antibody development after kidney and pancreas transplantation.

Background: De novo donor-specific antibodies (dnDSA) post-transplant correlate with a higher risk of immunologic graft injury and loss following kidney and pancreas transplantation. Post-transplant dnDSA can occur within the first post-transplant year.

Methods: In this study, 817 of 1290 kidney and simultaneous kidney/pancreas recipients were tested for dnDSA post-transplant.

Effects of cardiovascular comorbidity adjustment on SRTR risk-adjusted cox proportional hazard models of graft survival.

Background: The Scientific Registry of Transplant Recipients (SRTR) and the Centers for Medicare and Medicaid Services (CMS) determine expected graft survivals to identify potentially underperforming transplant centers. There has been recent interest in evaluating adjustments for comorbidities when performing these calculations. This study was performed to determine the influence that adjustment for pre-transplant cardiovascular disease comorbidity can have on risk-adjusted Cox models, such as those used by SRTR and CMS.

Antithymocyte globulin induction in living donor renal transplant recipients: final report of the TAILOR registry.

Background: The Thymoglobulin Antibody Immunosuppression in Living Donor Recipients registry was established to assess clinical experience with rabbit antithymocyte globulin (rATG; Thymoglobulin) in living donor renal transplant recipients.

Methods: From 2003 to 2008, US transplant centers prospectively entered information on patients who received rATG induction. In addition to standard United Network for Organ Sharing registry data elements, information was collected regarding immunosuppression, viral prophylaxis, acute rejection, and adverse events.

Peritubular capillary C4d staining in late acute renal allograft rejection--is it relevant?

Background: In the early post-transplant period, renal allograft rejection with diffuse peritubular capillary (PTC) C4d deposition predicts poor graft survival. In the late post-transplant setting, that is, one or more yr after transplantation, the implication of diffuse PTC C4d deposition is still a topic of debate. The purpose of our study was to see if diffuse PTC C4d deposition, in late acute rejection (LAR), occurring more than one yr post-transplant, has any impact on graft survival and function.

Steroid-free maintenance immunosuppression with rapamune and low-dose neoral in pancreas transplant recipients.

Background: Steroid-free immunosuppression is an attractive option because it avoids the many side effects of chronic corticosteroid use. It is especially attractive in pancreas recipients because it avoids the diabetogenic effects of steroids.

Methods: We evaluated the outcome of a steroid-free maintenance immunosuppressive protocol in pancreas transplant recipients.

Noninvasive methods to identify early vascular access dysfunction.

A functional vascular access is of critical importance to the hemodialysis patient, the patient's healthcare providers, and the hemodialysis treatment center. A poorly functioning or thrombosed vascular access can lead to increased morbidity, hospitalization, length of stay, and cost. This article reviews the increasing evidence supporting surveillance of arteriovenous (AV) hemodialysis access and the various strategies and techniques available for detection of a failing access.

Evolution of immunosuppression in kidney transplantation: the Ohio State University experience.

The goals and outcomes of immunosuppression in renal transplantation have changed significantly over the last 30 years. When graft survival rates were relatively low and acute rejection was a frequent occurrence in the early era of transplantation, the goal of immunosuppression was to improve survival and reduce the rate of acute rejection. Today, with excellent graft survival rates and a low incidence of acute rejection, the goal of immunosuppression has shifted toward not only eliminating acute rejection, but also toward reducing the side effects of medications, and maintaining long-term graft function by decreasing chronic nephropathy.

Excellent clinical outcomes in primary kidney transplant recipients treated with steroid-free maintenance immunosuppression.

Steroid-free maintenance immunosuppression is desirable to eliminate the side effects of chronic corticosteroid use. Complete steroid avoidance or rapid post-transplant steroid withdrawal has recently been used in renal transplant recipients with encouraging results. The present study evaluated the outcome of a steroid-free maintenance immunosuppressive protocol in kidney transplant recipients with at least one-yr follow up.

Routine surveillance in vascular access for hemodialysis.

There is increasing evidence that surveillance of AV access for haemodialysis prevents access thrombosis and improves the quality of care. This article reviews the evidence for surveillance and the various strategies and techniques available for detection of the failing access.

Improving the prediction of donor kidney quality: deceased donor score and resistive indices.

Background: The deceased donor score (DDS), expanded criteria donor (ECD) definition, and resistive index (RI) were developed for pretransplant evaluation of donors. DDS and ECD are determined by a calculation of risk from donor variables, while RI is determined from flow characteristics of kidneys during machine preservation (MP). This study was designed to compare DDS, ECD status, and RI as predictors of outcome after deceased donor transplantation.

Hand-assisted laparoscopic versus open nephrectomies in living donors.

Unlabelled: Shortages of cadaveric kidneys for transplant into rising numbers of patients with end-stage renal failure have increased the demand for kidneys from live donors. The morbidity associated with traditional open donor nephrectomies (ODN) may discourage many candidates. The newer laparoscopic technique has been promoted as having less morbidity.

Magnetic resonance cholangiography with mangafodipir trisodium (Teslascan) to evaluate bile duct leaks after T-tube removal in liver transplantation.

Liver transplant patients who present with abdominal pain after removal of the T-tube can be initially evaluated by contrast-enhanced magnetic resonance cholangiography (CEMRC) instead of abdominal computed tomography and hepatobiliary scintigraphy. In this article, 3 liver transplant patients who were evaluated by CEMRC after removal of the T-tube. CEMRC successfully identified the presence, location and extent of bile duct leaks, and can be performed as a diagnostic study in patients with suspected bile duct leaks.

Simultaneous pancreas-kidney transplantation at a single center.

Simultaneous pancreas-kidney transplantation (SPKT) is the procedure of choice in our program to treat type I diabetic patients with end-stage renal disease. Its value in type II diabetic patients remains to be carefully evaluated. With the improvements in the technical results and immunosuppression medications, the procedures have become safer than those performed in the previous decade.

Procurement of liver and pancreas allografts in donors with replaced/accessory right hepatic arteries.

Anatomic variants in the origin of the right hepatic artery have led to various approaches at the time of organ procurement for transplantation. Of special relevance is the presence of a replaced or accessory right hepatic artery arising independently from the superior mesenteric artery. On the basis of an estimated combined experience of almost 2,000 organ procurements and implantations, we propose a technique in which dissection is kept to a minimum, with the goal of preventing procurement-associated injuries.

Magnetic resonance angiography for preoperative evaluation of potential kidney donors.

Background: Careful evaluation of the renovascular anatomy for living kidney donors is essential to optimize donor and recipient outcomes. Arteriography has been the standard for delineating the renovascular anatomy. However, this procedure is invasive.

Twenty years of renal transplantation at Ohio State University: the results of five eras of immunosuppression.

Over the past 20 years, more than 4,000 patients have undergone an abdominal solid organ transplant at Ohio State University. The 20-year period can be divided into five eras, each defined by an immunosuppressive protocol used during that period. With each successful era came a new immunosuppressive protocol that produced an incremental improvement in outcomes of patients and graft survival resulting from the application of the newest and most sophisticated combination of immunosuppressive drugs.