American Journal of Kidney Diseases最新文献

The Organ Procurement and Transplant Network (OPTN) Expeditious Task Force (ETF) was conceived and initiated in response to a need to move quickly to greatly expand successful deceased-donor transplant across the United States. The ETF, using data from the top 20% of transplant programs ranked by ability to manage successful growth in transplant volume, came up with a bold aim of facilitating 60,000 successful transplants by 2026 to save more lives. In order to achieve this transformational growth, the ETF will use a data-driven approach, partnering with key stakeholders across the transplant system to secure commitments, reduce barriers, obtain data, align metrics, evaluate new technologies, and run short trials that will better inform future policy developments. To achieve this growth, the 2 primary aims of the ETF are increasing system efficiency and improving organ and donor utilization. The initial ETF work streams will focus on 6 areas: (1) assessments of organ nonutilization (where donors are consented but organs not recovered) and nonuse (where organs are recovered but not transplanted), (2) facilitating community events to address challenges in utilization and efficiency, (3) hosting transplant growth collaboratives focused on securing resources needed for transformational growth, (4) creating tools for patient empowerment, (5) evaluating OPTN policies to remove barriers, and (6) designing short trials of rescue pathways for organs at risk for nonuse.

Viral-associated nephropathy is when kidney disease results from active viral replication. Because of the high global burden of viral infections, clinicians should be aware of their incidence, kidney manifestations, mechanism of injury, and management. Some viruses, such as hepatitis B, hepatitis C, human immunodeficiency virus (HIV), and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), can lead to nephropathy more commonly than other endemic viruses, such as Epstein-Barr virus, cytomegalovirus, and polyoma virus which are more important causes of nephropathy in the immunosuppressed patient. Other viruses, such as hantavirus and dengue virus, have a high global infectivity rate with rare but severe kidney manifestations. Advances over the past decades have offered us a better understanding of the pathogenesis of viral-associated nephropathies and antiviral therapy options. The patterns of kidney injury include glomerular and tubulointerstitial lesions in the setting of acute and chronic infection. Direct viral infection of kidney parenchymal cells may drive pathologic findings, but kidney pathology may also result from indirect mechanisms due to activation of the innate and adaptive immune system. Some viruses can cause kidney injury due to altered hemodynamics from liver dysfunction or shock. More information about the role of genetics, specifically APOL1 polymorphisms, has come to light in regard to HIV-associated nephropathy and SARS-CoV-2-associated nephropathy. Advances in antiviral therapy help reduce nephrotoxicity and improve morbidity and mortality. In this Core Curriculum, we review common viruses responsible for kidney disease worldwide, discuss mechanisms of pathogenesis, and highlight specific management principles of viral nephropathies. We also discuss other viruses with high endemicity despite low incidence of kidney disease in the immunocompetent and immunosuppressed host.

Rationale & objective: Prescribing psychoactive medications for patients with kidney disease is common, but for patients receiving dialysis, some medications may be inappropriate. We evaluated the association of coprescribing gabapentinoids and other psychoactive potentially inappropriate medications (PPIMs) (e.g., sedatives, opioids) with altered mental status (AMS) and falls, and whether the associations are modified by frailty.

Study design: Observational cohort study.

Setting: & Participants: Adults receiving dialysis represented in the United States Renal Data System who had an active gabapentinoid prescription and no other PPIM prescriptions in the prior 6 months.

Exposure: PPIM coprescribing, or the presence of overlapping prescriptions of a gabapentinoid and ≥1 additional PPIM.

Outcomes: Acute care visits for AMS and injurious falls.

Analytical approach: Prentice-Williams-Petersen Gap Time models estimated the association between PPIM coprescribing and each outcome, adjusting for demographics, comorbidities, and frailty (assessed by a validated frailty index (FI)). Each model tested for interaction between PPIM coprescribing and frailty.

Results: Overall, PPIM coprescribing was associated with increased hazard of AMS (HR: 1.66 [95% CI 1.44, 1.92]) and falls (HR: 1.55 [95% CI 1.36, 1.77]). Frailty significantly modified the effect of PPIM coprescribing on the hazard of AMS (interaction p=0.01), but not falls. Among individuals with low frailty (FI=0.15), the hazard ratio for AMS with PPIM co-prescribing was 2.14 (95% CI: 1.69, 2.71); while for individuals with severe frailty (FI=0.34), the hazard ratio for AMS with PPIM coprescribing was 1.64 (95% CI: 1.42, 1.89). Individuals with PPIM coprescribing and severe frailty (FI =0.34) had the highest hazard of AMS [HR 4.04 (95% CI: 3.20, 5.10)] and falls [HR 2.77 (95% CI: 2.27, 3.38)] compared to non-frail individuals without PPIM coprescribing.

Limitations: Outcome ascertainment bias; residual confounding.

Conclusions: Compared to gabapentinoid prescriptions alone, PPIM coprescribing was associated with an increased risk of AMS and falls. Clinicians should consider these risks when coprescribing PPIMs to patients receiving dialysis.

Rationale & objective: The kidney allocation system (KAS250), using circle-based distribution, attempts to address geographic disparities through broader sharing of deceased-donor kidney allografts. This study sought to evaluate the association between KAS250 and likelihood of deceased-donor kidney transplantation (DDKT) among waitlisted candidates, and whether the policy has differentially affected centers with shorter vs. longer waiting time.

Study design: Retrospective cohort study.

Setting: & Participants: 160,941 candidates waitlisted at 176 transplant centers between 3/2017-3/2024.

Exposure: KAS250 allocation policy.

Outcome: Rate of DDKT.

Analytical approach: Multivariable Cox regression, modeling KAS250 as a time-dependent variable.

Results: KAS250 was not independently associated with likelihood of DDKT overall (HR=1.01 vs. pre-KAS250, 95% C.I. 0.97-1.04). KAS250's association with likelihood of DDKT varied across centers from HR=0.18 (DDKT less likely after KAS250) to HR=17.12 (DDKT more likely) and varied even among neighboring centers. KAS250 was associated with decreased DDKT at 25.6% and increased DDKT at 18.2% of centers. Centers with previously long median waiting times (57+ months) experienced increased likelihood of DDKT after KAS250 (HR=1.20, 95% C.I. 1.15-1.26), whereas centers with previously short median waiting times (6-24mo.; HR=0.88, 0.84-0.92) experienced decreased likelihood of DDKT.

Limitations: Retrospective study of allocation policy changes, confounded by multiple changes over the study timeframe.

Conclusion: Association between KAS250 and DDKT varied across centers. For one-in-four centers, DDKT was less likely after KAS250 relative to pre-KAS250 trends. Candidates at centers with previously long waiting times experienced increased likelihood of DDKT after KAS250. Thus, broader distribution of kidneys may be associated with improved equity in access to DDKT, but additional strategies may be needed to minimize disparities between centers.