Assessing Predictors of Early and Late Hospital Readmission After Kidney Transplantation Background. A better understanding of the risk factors of posttransplant hospital readmission is needed to develop accurate predictive models. Methods. We included 40 461 kidney transplant recipients from United States renal data system (USRDS) between 2005 and 2014. We used Prentice, Williams and Peterson Total time model to compare the importance of various risk factors in predicting posttransplant readmission based on the number of the readmissions (first vs subsequent) and a random forest model to compare risk factors based on the timing of readmission (early vs late). Results. Twelve thousand nine hundred eighty-five (31.8%) and 25 444 (62.9%) were readmitted within 30 days and 1 year postdischarge, respectively. Fifteen thousand eight hundred (39.0%) had multiple readmissions. Predictive accuracies of our models ranged from 0.61 to 0.63. Transplant factors remained the main predictors for early and late readmission but decreased with time. Although recipients’ demographics and socioeconomic factors only accounted for 2.5% and 11% of the prediction at 30 days, respectively, their contribution to the prediction of later readmission increased to 7% and 14%, respectively. Donor characteristics remained poor predictors at all times. The association between recipient characteristics and posttransplant readmission was consistent between the first and subsequent readmissions. Donor and transplant characteristics presented a stronger association with the first readmission compared with subsequent readmissions. Conclusions. These results may inform the development of future predictive models of hospital readmission that could be used to identify kidney transplant recipients at high risk for posttransplant hospitalization and design interventions to prevent readmission. Received 24 May 2019. Accepted 1 June 2019. Published online 29 July, 2019. J.H. and R.E.P. participated in the conception of the paper, analysis of the data, and writing of the manuscript. M.D.A., S.M.A., K.L., X.Z., and R.Z. participated in the data analysis. A.B.A. participated in the conception of the paper and writing of the manuscript. J.F., R.J.L., and J.S. participated in the writing of the manuscript. All the authors have revised the article and approved the final version. The authors have no conflicts of interest to disclose. This work was supported by R01 MD011682. M.D.A. was supported in part by the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number UL1TR002378 as well as TL1TR002382. Supplemental digital content (SDC) is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (www.transplantationdirect.com). Supplement figure is available at http://links.lww.com/TXD/A215 Correspondence: Rachel Patzer, PhD, Department of Surgery, Emory Transplant center, Emory University School of medicine, 5001 Woodruff Memorial Research Building, 101 Woodruff Circle, Atlanta, GA. (rpatzer@emory.edu). This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. © 2019 The Authors. Published by Wolters Kluwer Health, Inc.

Hyperacute Antibody-mediated Rejection Associated With Red Blood Cell Antibodies No abstract available

Class and Kinetics of Weakly Reactive Pretransplant Donor-specific HLA Antibodies Predict Rejection in Kidney Transplant Recipients Background. The clinical impact of weakly reactive pretransplant donor-specific antibody (DSA) in kidney transplantation is controversial. While some evidence suggests that weakly reactive DSA can lead to rejection, it is unclear which patients are at risk for rejection and whether posttransplant changes in weakly reactive DSA are clinically meaningful. Methods. We retrospectively studied 80 kidney transplant recipients with weakly reactive pretransplant DSA between 2007 and 2014. We performed a multivariate Cox regression analysis to identify immunologic factors most associated with risk of biopsy-proven rejection. Results. Biopsy-proven rejection occurred in 13 of 80 (16%) patients. The presence of both class I and II DSA before transplant (hazards ratio 17.4, P < 0.01) and any posttransplant increase in DSA reactivity above a mean fluorescence intensity of 3000 (hazards ratio 7.8, P < 0.01) were each significantly associated with an increased risk of rejection, which primarily occurred within the first 18 months. Conclusions. Pretransplant DSA class and DSA kinetics after transplantation are useful prognostic indicators in patients with weak DSA reactivity. These results identify a small, high-risk patient group that warrants aggressive posttransplant DSA monitoring and may benefit from alternative donor selection. Received 31 May 2019. Accepted 19 June 2019. Published online 25 July, 2019. A.H.M. and M.G. contributed equally to this work. A.H.M., M.G., D.S., M.K., and P.M.P. designed the research project. A.H.M., M.A.L., K.L., J.T.C., and M.H.L. acquired the data. A.H.M. and M.G. performed the data analysis. A.H.M., M.G., and P.M.P. wrote the manuscript. All authors contributed to the revision and approval of the manuscript. M.K. serves on the Advisory Scientific Board of Omixon Inc. M.H.L. receives study drug from Pfizer, Inc. The institution has received research funding from Veloxis Pharmaceuticals Inc. A.H.M. was supported in part by the University of Pennsylvania Agnew Summer Scholars Research Program. Supplemental digital content (SDC) is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (www.transplantationdirectjournal.com) Correspondence: Paige M. Porrett, MD, PhD, Department of Surgery, University of Pennsylvania, 3400 Spruce Street, 2 Dulles Courtyard, Philadelphia, PA 19104. (paige.porrett@uphs.upenn.edu). This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. © 2019 The Authors. Published by Wolters Kluwer Health, Inc.

Postdonation eGFR and New‐Onset Antihypertensive Medication Use After Living Kidney Donation No abstract available

Low-dose Rituximab and Thymoglobulin Induction With Steroid-free Maintenance Immunosuppression and Protocol Biopsies Improves Long-term Patient and Graft Survival After Kidney Transplantation: Survival and Safety Outcomes in More Than 1100 Patients From a Single Center Background. Steroid-free maintenance immunosuppression after kidney transplantation provides acceptable patient and graft survival and minimizes steroid-associated side effects among recipients with a low immunological risk. However, the long-term outcomes of such protocols, incorporating low-dose rituximab and thymoglobulin induction along with protocol biopsies, in non-European populations remains underreported. Methods. We retrospectively analyzed 1142 consecutive kidney transplantations conducted at our center from July 2005 to October 2017. Immunosuppression protocol included induction with thymoglobulin and low-dose preoperative rituximab. Maintenance immunosuppression consisted of tacrolimus and mycophenolate mofetil; prednisolone was discontinued on postoperative day 5. Protocol biopsies were carried out at 3 months and at 1, 5, and 10 years after transplantation—in addition to the indicated biopsies. The 12-year patient and graft survival and posttransplantation complications were studied. Results. The analysis of outcomes was conducted for 1111 transplant recipients. Patients (70.59%) remained steroid-free at 12 years after transplantation. The patient survival rates at 1, 5, and 12 years were 97.7%, 94.8%, and 92.4%, respectively. The corresponding graft survival rates were 97.2%, 90.9%, and 86.1%, respectively. Biopsy-proven acute rejection occurred in 12.7% of recipients, including 3.5% subclinical rejections. The cumulative incidence of graft loss was 6.56% at 12.3 years. The overall incidence of death was 5.3%. Conclusions. Steroid-free maintenance immunosuppression was associated with excellent long-term patient and graft survival rates and reduced incidence of prednisolone-related side effects, despite acceptable rejection rates. Low-dose rituximab with thymoglobulin induction with immediate steroid withdrawal and surveillance biopsies resulted in excellent long-term outcomes in our single-center experience. Received 18 January 2019. Revision received 4 June 2019. Accepted 11 June 2019. Published online 25 July, 2019. V.P. has performed research design, article writing, and review. D.M. has performed research design and article review. N.K. has performed research design and article review. S.K. has performed research design and article review. V.R. has performed research design and article review. S.B. has performed research design and article review. G.B.-K. has performed article review. The authors declare no funding or conflicts of interest. Correspondence: Vivek Pathak, MD, DNB, Consultant Nephrologist, Department of Nephrology, Kovai Medical Center, Avinashi Rd, Coimbatore, Tamil Nadu 641014, India. (drvivekpathak@gmail.com). This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. © 2019 The Authors. Published by Wolters Kluwer Health, Inc.

Creation of a Robotically Assisted Terminal Jejunogastrostomy Is Safe and Effective in Regaining Antegrade Enteral Bile Duct Access After Live Donor Liver Transplant With Roux Limb No abstract available

Practice and Attitudes of Donor Coordinator Roles Regarding Physical Examination of Potential Organ and Tissue Donors in Australia Background. Physical examination of potential organ and tissue donors is standard practice to mitigate risks and optimize outcomes for transplant recipients, but the content and process of the examination has not been investigated. The aim of this study was to determine current practice of performing a physical examination on potential organ and tissue donors in Australia. Methods. An online cross-sectional survey was circulated to all Australian Donor Coordinators (n = 125). Results. There were 75 responses (60% response rate) to the online survey. Respondents perform a mean 10.5 physical examinations per year. Inconsistencies were observed in the approach to the physical examination, inclusive of assessment techniques used to perform the examination such as palpation. Specific staff training and education to perform the examination was reportedly provided to 77% of respondents. There was less variation reported in examination findings classified as higher risk and escalation procedures with the 3 most common findings of injection sites / track marks (86%), suspicious moles (77%), and unexplained scarring (51%), and with 97% seeking a second opinion. Current and previously removed melanomas were the main examination findings that stopped a donation from proceeding, as reported to have occurred by 18 respondents. Conclusions. This study has identified variations in current physical examination practice and provided the evidence to pursue practice improvement. The inconsistencies can be partly attributed to discrepancies in training and education of staff and no standardized national guidelines to clearly outline expected practice. Received 9 January 2019. Revision received 29 April 2019. Accepted 30 April 2019. Published online 23 July, 2019. J.A.C.H. contributed to the conception and design of the study and development of the survey instrument and performed the research, data analysis, and writing of the article. K.R. contributed to the planning and design of the study, survey instrument, data analysis, and revisions of the article. K.B. contributed to the planning of data analysis and revisions of the article. M.J. contributed to the development of the survey instrument. F.V.H. contributed to the design of the study, survey instrument, data analysis, and revision of the article for important intellectual content. The authors declare no funding or conflicts of interest. DonateLife ACT and University of Canberra contributed funding to cover the costs of publication. Supplemental digital content (SDC) is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site(www.transplantationdirect.com). Correspondence: Frank Van Haren, MD, PhD, EDIC, FCICM, Intensive Care Unit, Canberra Hospital, PO Box 11, Woden, ACT 2606, Australia. (frank.vanharen@act.gov.au). This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. © 2019 The Authors. Published by Wolters Kluwer Health, Inc.

Pancreas Retransplant After Pancreas Graft Failure in Simultaneous Pancreas-kidney Transplants Is Associated With Better Kidney Graft Survival Background. Simultaneous pancreas-kidney (SPK) transplant is usually the best option for the diabetic end-stage renal disease patient. There is limited information about kidney graft outcomes in SPK recipients with isolated pancreas graft failure who do versus do not undergo pancreas retransplantation. Methods. Patients were divided into 2 groups based on whether they underwent pancreas retransplant (ReTx+) or not (ReTx−). Kidney graft function and survival were the primary endpoints. Results. One hundred and nine patients satisfied our selection criteria, 25 in ReTx+ and 84 in ReTx−. Mean interval from SPK to pancreas failure was significantly shorter in the ReTx+ compared with the ReTx− group, 19.3 ± 36.7 versus 45.7 ± 47.0 months (P = 0.01), respectively. There was no significant difference in kidney graft follow-up post SPK between 2 groups (P = 0.48). At last follow-up, 15 of the 25 (60%) of the repeat pancreas graft had failed, with a mean graft survival among these failed pancreas graft of 2.6 ± 2.7 years, ranging from 0 to 8.1 years. Uncensored kidney graft failure was significantly lower in the ReTx+ group compared with the ReTx− group, 44% versus 67% (P = 0.04). Death-censored kidney graft failure was also lower in the ReTx+ group, 24% versus 48% (P = 0.04). The difference in patient survival did not reach statistical significance. In adjusted Cox regression analysis, rejection as a cause of pancreas failure was associated with increased risk of death-censored kidney graft failure, and pancreas retransplantation was associated with decreased risk of kidney graft failure. A similar pattern was seen after 1:1 matching for the interval between SPK and pancreas graft failure. Conclusions. Even though ReTx+ patients accept the risks associated with repeat pancreas surgery, providers should consider this option in suitable otherwise healthy patients. Received 29 May 2019. Revision received 6 June 2019. Accepted 8 June 2019. Published online 23 July, 2019. The authors declare no conflicts of interest. This work was supported by an unrestricted research grant from the Virginia Lee Cook Foundation. The clinical and research activities being reported are consistent with the Principles of the Declaration of Istanbul as outlined in the Declaration of Istanbul on Organ Trafficking and Transplant Tourism. S.P. participated in study concept, design, data collection, analysis, manuscript preparation, and editing. A.A., K.S., and N.G. performed data collection, manuscript preparation, and editing. F.A., N.G., R.R., D.K., and A.D. participated in manuscript preparation and editing. N.B. performed data collection and editing. J.O. participated in study concept, design, analysis, manuscript preparation, and editing. D.M. and J.O. contributed equally to this study. Correspondence: Sandesh Parajuli, MBBS, UW Medical Foundation Centennial Building 4175, 1685 Highland Avenue, Madison, WI 53705. (sparajuli@medicine.wisc.edu). This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. © 2019 The Authors. Published by Wolters Kluwer Health, Inc.

Excellent Contemporary Graft Survival for Adult Liver Retransplantation: An Australian and New Zealand Registry Analysis From 1986 to 2017 Background. Liver retransplantation is technically challenging, and historical outcomes are significantly worse than for first transplantations. This study aimed to assess graft and patient survival in all Australian and New Zealand liver transplantation units. Methods. A retrospective cohort analysis was performed using data from the Australia and New Zealand Liver Transplant Registry. Graft and patient survival were analyzed according to era. Cox regression was used to determine recipient, donor, or intraoperative variables associated with outcomes. Results. Between 1986 and 2017, Australia and New Zealand performed 4514 adult liver transplants, 302 (6.7%) of which were retransplantations (278 with 2, 22 with 3, 2 with 4). The main causes of graft failure were hepatic artery or portal vein thrombosis (29%), disease recurrence (21%), and graft nonfunction (15%). Patients retransplanted after 2000 had a graft survival of 85% at 1 year, 75% at 5 years, and 64% at 10 years. Patient survival was 89%, 81%, and 74%, respectively. This was higher than retransplantations before 2000 (P < 0.001). Univariate analysis found that increased recipient age (P = 0.001), recipient weight (P = 0.019), and donor age (P = 0.011) were associated with decreased graft survival prior to 2000; however, only increased patient weight was significant after 2000 (P = 0.041). Multivariate analysis found only increased recipient weight (P = 0.042) and donor age (P = 0.025) was significant prior to 2000. There was no difference in survival for second and third retransplants or comparing time to retransplant. Conclusions. Australia and New Zealand have excellent survival following liver retransplantation. These contemporary results should be utilized for transplant waitlist methods. Received 15 May 2019. Accepted 31 May 2019. Published online 23 July, 2019. A.W.J. participated in research design, the writing of the paper, the performance of the research, and data analysis. L.D., G.M., M.C., P.A., R.J., G.A.M., J.F., A.W., J.C., E.G., and S.M. participated in data collection and peer review. G.P.J. participated in research design, the writing of the paper, and peer review. The authors declare no funding or conflicts of interest. Correspondence: Angus Jeffrey, MD, Sir Charles Gairdner Hospital, Hospital Ave, Nedlands, WA 6010, Australia. (angus.jeffrey@health.wa.gov.au). This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. © 2019 The Authors. Published by Wolters Kluwer Health, Inc.