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The proportion of kidneys procured for transplantation but not utilized exceeds 20% in the United States. Factors associated with nonutilization are complex, and further understanding of novel causes are critically important. We used the national Scientific Registry of Transplant Recipients data (2010-2022) to evaluate associations of Distressed Community Index (DCI) of deceased donor residence and likelihood of kidney nonutilization (n = 209 413). Deceased donors from higher distressed communities were younger, had an increased history of hypertension and diabetes, were CDC high-risk, and had higher terminal creatinine and donation after brain death. Mechanisms and circumstances of death varied significantly by DCI. The proportion of kidney nonutilization was 19.9%, which increased by DCI quintile (Q1 = 18.1% to Q5 = 21.6%). The adjusted odds ratio of nonutilization from the highest quintile DCI communities was 1.22 (95% CI = 1.16-1.28; reference = lowest DCI), which persisted stratified by donor race. Donors from highly distressed communities were highly variable by the donor service area (range: 1%-51%; median = 21%). There was no increased risk for delayed graft function or death-censored graft loss by donor DCI but modest increased adjusted hazard for overall graft loss (high DCI = 1.05; 95% CI = 1.01-1.10; reference = lowest DCI). Results indicate that donor residential distress is associated with significantly higher rates of donor kidney nonutilization with notable regional variation and minimal impact on recipient outcomes.

Peritransplant TNF blockade with infliximab should not be used in recipients of deceased-donor kidney transplants due to lack of efficacy and an increased incidence of BK virus infection, according to results of a randomized controlled clinical trial. Our results underscore the need for properly controlled and powered trials to avoid falsely accepting unproven therapeutics and reporting incorrect low adverse event rates derived from small, uncontrolled experiments.

Emerging data support the safety of transplantation of extra-pulmonary organs from donors with SARS-CoV-2-detection. Our center offered kidney transplantation (KT) from deceased donors (DD) with SARS-CoV-2 with and without COVID-19 as a cause of death (CoV + COD and CoV+) to consenting candidates. No pre-emptive antiviral therapies were given. We retrospectively compared outcomes to contemporaneous DDKTs with negative SARS-CoV-2 testing (CoVneg). From February 1, 2021 to January 31, 2022, there were 220 adult KTs, including 115 (52%) from 35 CoV+ and 33 CoV + COD donors. Compared to CoVneg and CoV+, CoV + COD were more often DCD (100% vs. 40% and 46%, p< .01) with longer cold ischemia times (25.2 h vs. 22.9 h and 22.2 h, p= .02). At median follow-up of 5.7 months, recipients of CoV+, CoV + COD and CoVneg kidneys had similar rates of delayed graft function (10.3%, 21.8% and 21.9%, p= .16), rejection (5.1%, 0% and 8.5%, p= .07), graft failure (1.7%, 0% and 0%, p= .35), mortality (0.9%, 0% and 3.7%; p= .29), and COVID-19 diagnoses (13.6%, 7.1%, and 15.2%, p= .33). Though follow-up was shorter, CoV + COD was associated with lower but acceptable eGFR on multivariable analysis. KT from DDs at various stages of SARS-CoV-2 infection appears safe and successful. Extended follow-up is required to assess the impact of CoV + COD donors on longer term graft function.

Coronavirus disease‐19 has had a marked impact on the transplant population and processes of care for transplant centers and organ allocation. Several single‐center studies have reported successful utilization of deceased donors with positive severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) tests. Our aims were to characterize testing, organ utilization, and transplant outcomes with donor SARS‐CoV‐2 status in the United States. We used Scientific Registry of Transplant Recipients data from March 12, 2020 to August 31, 2021 including a custom file with SARS‐CoV‐2 testing data. There were 35 347 donor specimen SARS‐CoV‐2 tests, 77.5% upper respiratory samples, 94.6% polymerase chain reaction tests, and 1.2% SARS‐CoV‐2–positive tests. Donor age, gender, history of hypertension, and diabetes were similar by SARS‐CoV‐2 status, while positive SARS‐CoV‐2 donors were more likely African‐American, Hispanic, and donors after cardiac death (p‐values <.01). Recipient demographic characteristics were similar by donor SARS CoV‐2 status. Adjusted donor kidney discard (odds ratio = 2.08, 95% confidence interval [CI] 1.66–2.61) was higher for SARS‐CoV‐2–positive donors while donor liver (odds ratio = 0.44, 95% CI 0.33–0.60) and heart recovery (odds ratio = 0.44, 95% CI 0.31–0.63) were significantly reduced. Overall post‐transplant graft survival for kidney, liver, and heart recipients was comparable by donor SARS‐CoV‐2 status. Cumulatively, there has been significantly lower utilization of SARS‐CoV‐2 donors with no evidence of reduced recipient graft survival with variations in practice over time. Organs from donors with positive SARS‐CoV‐2 tests, compared to those from donors with negative tests, have been used with reduced frequency but are associated with similar outcomes for kidney, liver and heart recipients.

The primary outcomes for kidney transplant candidates are receipt of deceased or living donor transplant, death or removal from the waiting list. Here, we conducted a retrospective analysis of national Scientific Registry of Transplant Recipients data to evaluate outcomes for 208,717 adult kidney transplant candidates following the 2014 Kidney Allocation System in the United States. Competing risks models were utilized to evaluate Time to Equivalent Risk (TiTER) of deceased donor transplantation (DDTX) and death versus waitlist removal. We also evaluated TiTER based on kidney donor profile index (KDPI) and donor age. For all groups, the cumulative incidence of DDTX was initially higher from time of listing than death or waitlist removal. However, following accrued time on the waiting list, the cumulative incidence of death or waitlist removal exceeded DDTX for certain patient groups, particularly older, diabetic, blood type B and O and shorter pre-listing dialysis time. TiTER for all candidates aged 65-69 averaged 41 months and for 70 and older patients 28 months. Overall, 39.6% of candidates were in risk groups with TiTER under 72 months and 18.5% in groups with TiTER under 24 months. Particularly for older candidates, TiTER for kidneys was substantially shorter for younger donors or lower KDPI. Thus, our findings reveal that a large proportion of wait-listed patients in the United States have poor prognoses to ever undergo DDTX and our data may improve shared decision-making for candidates at time of waitlist placement. Hence, for specific patient groups, TiTER may be a useful tool to disseminate and quantify benefits of accepting relatively high risk donor organs.

The Kidney Precision Medicine Project (KPMP) seeks to establish a molecular atlas of the kidney in health and disease and improve our understanding of the molecular drivers of CKD and AKI. Herein, we describe the case of a 66-year-old woman with CKD who underwent a protocol KPMP kidney biopsy. Her clinical history included well-controlled diabetes mellitus, hypertension, and proteinuria. The patient?s histopathology was consistent with modest hypertension-related kidney injury, without overt diabetic kidney disease. Transcriptomic signatures of the glomerulus, interstitium, and tubular subsegments were obtained from laser microdissected tissue. The molecular signatures that were uncovered revealed evidence of early diabetic kidney disease adaptation and ongoing active tubular injury with enriched pathways related to mesangial cell hypertrophy, glycosaminoglycan biosynthesis, and apoptosis. Molecular evidence of diabetic kidney disease was found across the nephron. Novel molecular assays can supplement and enrich the histopathologic diagnosis obtained from a kidney biopsy.

Transplantation of solid organs from donors with active SARS‐CoV‐2 infection has been advised against due to the possibility of disease transmission to the recipient. However, with the exception of lungs, conclusive data for productive infection of transplantable organs do not exist. While such data are awaited, the organ shortage continues to claim thousands of lives each year. In this setting, we put forth a strategy to transplant otherwise healthy extrapulmonary organs from SARS‐CoV‐2‐infected donors. We transplanted 10 kidneys from five deceased donors with new detection of SARS‐CoV‐2 RNA during donor evaluation in early 2021. Kidney donor profile index ranged from 3% to 56%. All organs had been turned down by multiple other centers. Without clear signs or symptoms, the veracity of timing of SARS‐CoV‐2 infection could not be confirmed. With 8–16 weeks of follow‐up, outcomes for all 10 patients and allografts have been excellent. All have been free of signs or symptoms of donor‐derived SARS‐CoV‐2 infection. Our findings raise important questions about the nature of SARS‐CoV‐2 RNA detection in potential organ donors and suggest underutilization of exceptionally good extrapulmonary organs with low risk for disease transmission. The authors present a case series of successful kidney transplantation from donors with newly detected SARS‐CoV‐2, highlighting the potential underutilization of such organs.

Current short‐term kidney post–transplant survival rates are excellent, but longer‐term outcomes have historically been unchanged. This study used data from the national Scientific Registry of Transplant Recipients (SRTR) and evaluated 1‐year and 5‐year graft survival and half‐lives for kidney transplant recipients in the US. All adult (≥18 years) solitary kidney transplants (n= 331,216) from 1995 to 2017 were included in the analysis. Mean age was 49.4 years (SD +/‐13.7), 60% male, and 25% Black. The overall (deceased and living donor) adjusted hazard of graft failure steadily decreased from 0.89 (95%CI: 0.88, 0.91) in era 2000–2004 to 0.46 (95%CI: 0.45, 0.47) for era 2014–2017 (1995–1999 as reference). Improvements in adjusted hazards of graft failure were more favorable for Blacks, diabetics and older recipients. Median survival for deceased donor transplants increased from 8.2 years in era 1995–1999 to an estimated 11.7 years in the most recent era. Living kidney donor transplant median survival increased from 12.1 years in 1995–1999 to an estimated 19.2 years for transplants in 2014–2017. In conclusion, these data show continuous improvement in long‐term outcomes with more notable improvement among higher‐risk subgroups, suggesting a narrowing in the gap for those disadvantaged after transplantation. Analysis of a large registry database shows that, in the United States, long‐term kidney allograft survival is steadily improving with larger improvement in recipients who are elderly, Black, or diabetic.

The COVID‐19 pandemic has affected all portions of the global population. However, many factors have been shown to be particularly associated with COVID‐19 mortality including demographic characteristics, behavior, comorbidities, and social conditions. Kidney transplant candidates may be particularly vulnerable to COVID‐19 as many are dialysis‐dependent and have comorbid conditions. We examined factors associated with COVID‐19 mortality among kidney transplant candidates from the National Scientific Registry of Transplant Recipients from March 1 to December 1, 2020. We evaluated crude rates and multivariable incident rate ratios (IRR) of COVID‐19 mortality. There were 131 659 candidates during the study period with 3534 all‐cause deaths and 384 denoted a COVID‐19 cause (5.00/1000 person years). Factors associated with increased COVID‐19 mortality included increased age, males, higher body mass index, and diabetes. In addition, Blacks (IRR = 1.96, 95% C.I.: 1.43–2.69) and Hispanics (IRR = 3.38, 95% C.I.: 2.46–4.66) had higher COVID‐19 mortality relative to Whites. Patients with lower educational attainment, high school or less (IRR = 1.93, 95% C.I.: 1.19–3.12, relative to post‐graduate), Medicaid insurance (IRR = 1.73, 95% C.I.: 1.26–2.39, relative to private), residence in most distressed neighborhoods (fifth quintile IRR = 1.93, 95% C.I.: 1.28–2.90, relative to first quintile), and most urban and most rural had higher adjusted rates of COVID‐19 mortality. Among kidney transplant candidates in the United States, social determinants of health in addition to demographic and clinical factors are significantly associated with COVID‐19 mortality. Social factors, including educational attainment, health insurance, and residential community income levels, along with demographic and clinical characteristics, are strongly associated with mortality among kidney transplant candidates with COVID‐19 in the United States.

Body mass index (BMI) is a known risk factor associated with kidney transplant outcomes and is incorporated for determining transplant candidate eligibility. However, BMI is a coarse health measure and risks associated with BMI may vary by patient characteristics. We evaluated 296 807 adult (age > 17) solitary kidney transplant recipients from the Scientific Registry of Transplant Recipients (2000‐2019). We examined effects of BMI using survival models and tested interactions with recipient characteristics. Overall, BMI demonstrated a “J‐Shaped” risk profile with elevated risks for overall graft loss with low BMI and obesity. However, multivariable models indicated interactions between BMI with recipient age, diagnosis, gender, and race/ethnicity. Low BMI was relatively higher risk for older recipients (>60 years), people with type I diabetes, and males and demonstrated no additional risk among younger (18‐39) and Hispanic recipients. High BMI was associated with elevated risk for Caucasians and attenuated risk among African Americans and people with type II diabetes. Effects of BMI had variable risks for mortality vs graft loss by recipient characteristics in competing risks models. The association of BMI with posttransplant outcomes is highly variable among kidney transplant recipients. Results are important considerations for personalized care and risk stratification. Findings suggest that transplant contraindications should not be based on absolute BMI thresholds but modified based on patient characteristics. While body mass index is a well‐established risk factor for inferior kidney transplant outcomes, this report shows that the impact is highly variable, with heterogeneity by recipient age, sex, race/ethnicity, and primary diagnosis.

There are emerging data depicting the clinical presentation of coronavirus disease 19 (COVID‐19) in solid organ transplant recipients but negligible data‐driven guidance on clinical management. A biphasic course has been described in some infected with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), beginning with a flu‐like illness followed by an intense inflammatory response characterized by elevated c‐reactive protein (CRP), interleukin 6 (IL‐6), and acute respiratory distress syndrome (ARDS) associated with high mortality. The exuberant and possibly dysregulated immune response has prompted interest in therapeutic agents that target the cytokines involved, particularly IL‐6. Tocilizumab is an IL‐6 receptor antagonist with a record of use for a variety of rheumatologic conditions and cytokine release syndrome due to chimeric antigen receptor T‐cell therapy but experience in solid organ and composite tissue transplant recipients (SOT/CTTRs) with SARS‐CoV‐2‐related ARDS has not been previously reported in detail. We present the clinical course of 5 SOT/CTTRs with SARS‐CoV‐2‐related ARDS that received tocilizumab with favorable short‐term outcomes in 4. Responses were characterized by reductions in CRP, discontinuation of vasopressors, improved oxygenation and respiratory mechanics, and variable duration of ventilator support. Four bacterial infections occurred within 2 weeks of tocilizumab administration. We discuss safety concerns and the need for randomized comparative trials to delineate tocilizumab's clinical utility in this population. The authors describe the clinical course of solid organ and vascularized composite allograft recipients with COVID‐19–related ARDS treated with tocilizumab.

Success of transplantation is not limited to initial receipt of a donor organ. Many kidney transplant recipients experience graft loss following initial transplantation and the benefits of expedited placement on the waiting list and retransplantation extend to this population. Factors associated with access to repeat transplantation may be unique given experience with the transplant process and prior viability as a candidate. We examined the incidence, risk factors, secular changes, and center‐level variation of preemptive relisting or transplantation (PRLT) for kidney transplant recipients in the United States with graft failure (not due to death) using Scientific Registry of Transplant Recipients data from 2007 to 2018 (n = 39 557). Overall incidence of PRLT was 15% and rates of relisting declined over time. Significantly lower PRLT was evident among patients who were African American and Hispanic, males, older, obese, publicly insured, had lower educational attainment, were diabetic, had longer dialysis time prior to initial transplant, shorter graft survival, longer distance to transplant center, and resided in distressed communities. There was significant variation in PRLT by center, median = 13%, 10th percentile = 6%, 90th percentile = 24%. Cumulatively, results indicate that despite prior access to transplantation, incidence of PRLT is modest with pronounced clinical, social, and center‐level sources of variation suggesting opportunities to improve preemptive care among patients with failing grafts. Despite significant advantages and established relationships with transplant centers, kidney transplant recipients with failing grafts are infrequently listed preemptively for retransplantation, with wide variation in frequency based on patient characteristics and initial transplant center.

Living kidney donation is widely practiced throughout the world. During the past 2 decades, various groups have provided guidance about the evaluation and care of living donors. However, during this time, our knowledge in the field has advanced substantially and many agreed on the need for a comprehensive, unifying document. KDIGO (Kidney Disease: Improving Global Outcomes) addressed this issue at an international level with the publication of its clinical practice guideline on the evaluation and care of living kidney donors. The KDIGO work group extensively reviewed the available literature and wrote a series of guideline recommendations using various degrees of evidence when available. As has become recent practice, NKF-KDOQI (National Kidney Foundation–Kidney Disease Outcomes Quality Initiative) convened a work group to provide a commentary on the KDIGO guideline, with a focus on how these recommendations apply in the context of the United States. In the United States, the United Network for Organ Sharing (UNOS) guides and regulates the practice of living kidney donation. While the KDIGO guideline for the care of living kidney donors and UNOS policy are similar in most aspects of the care of living kidney donors, several important areas are not consistent or do not align with common practice by US transplantation programs in areas in which UNOS has not set specific policy. For the time being, and recognizing the value of the KDIGO guidelines, US transplantation programs should continue to follow UNOS policy.

Animal models and observational human data indicate that complement, including C5a, pathogenically participates in ischemia reperfusion (IR) injury that manifests as delayed graft function (DGF) following deceased donor kidney transplantation. We report on the safety/efficacy of anti-C5 monoclonal antibody eculizumab (Ecu) administered in the operating room prior to reperfusion, to prevent DGF in recipients of deceased donor kidney transplants in two related, investigator-sponsored, randomized controlled trials. Eight recipients from a single center were enrolled in a pilot study that led to a 19-subject multicenter trial. Together, 27 deceased donor kidney transplant recipients, 16 Ecu-treated and 11 controls, were treated with rabbit antithymocyte globulin, tacrolimus, mycophenolate mofetil with or without glucocorticoids, and followed for 6 months. Data analysis showed no epidemiological or transplant-related differences between study arms. Ecu was well tolerated with a similar severe adverse event incidence between groups. The DGF rate did not differ between Ecu-treated (44%) and control (45%, P= 1.0) subjects. Serum creatinine reduction in the first week after transplantation, and graft function up to 180-days post-transplant, were also similar. Ecu administration was safe but did not reduce the rate of DGF in a high-risk population of deceased donor recipients.

Over recent decades, numerous clinical advances and policy changes have affected outcomes for candidates of kidney transplantation in the United States. We examined the national Scientific Registry for Transplant Recipients for adult (18+) solitary kidney transplant candidates placed on the waiting list for primary listing from 2001 to 2015. We evaluated rates of mortality, transplantation, and waitlist removal. Among 340 115 candidates there were significant declines in mortality (52 deaths/1000 patient years in 2001‐04 vs 38 deaths/1000 patient years in 2012‐15) and transplant rates (304 transplants/1000 patient years in 2001‐04 vs 212 transplants/1000 patient years in 2012‐15) and increases in waitlist removals (15 removals/1000 patient years in 2001‐04 vs 25/1000 patient years in 2012‐15) within the first year after listing. At 5 years an estimated 37% of candidates listed in 2012‐15 were alive without transplant as compared to 22% in 2001‐04. Declines in mortality over time were significantly more pronounced among African Americans, candidates with longer dialysis duration, and those with diabetes (P< .001). Cumulatively, results indicate dramatic changes in prognoses for adult kidney transplant candidates, likely impacted by selection criteria, donor availability, regulatory oversight, and clinical care. These trends are important considerations for prospective policy development and research, clinical and patient decision‐making, and evaluating the impact on access to care. Dramatic secular changes in the last 15 years in mortality, transplant, and waitlist removal rates for kidney transplant candidates affect patients’ prognosis and should be considered for decision‐making, research, and policy development. See Gupta and Abt's comments on page 313.

Noninvasive biomarkers are needed to monitor stable patients after kidney transplant (KT), because subclinical acute rejection (subAR), currently detectable only with surveillance biopsies, can lead to chronic rejection and graft loss. We conducted a multicenter study to develop a blood‐based molecular biomarker for subAR using peripheral blood paired with surveillance biopsies and strict clinical phenotyping algorithms for discovery and validation. At a predefined threshold, 72% to 75% of KT recipients achieved a negative biomarker test correlating with the absence of subAR (negative predictive value: 78%‐88%), while a positive test was obtained in 25% to 28% correlating with the presence of subAR (positive predictive value: 47%‐61%). The clinical phenotype and biomarker independently and statistically correlated with a composite clinical endpoint (renal function, biopsy‐proved acute rejection, ≥grade 2 interstitial fibrosis, and tubular atrophy), as well as with de novo donor‐specific antibodies. We also found that <50% showed histologic improvement of subAR on follow‐up biopsies despite treatment and that the biomarker could predict this outcome. Our data suggest that a blood‐based biomarker that reduces the need for the indiscriminate use of invasive surveillance biopsies and that correlates with transplant outcomes could be used to monitor KT recipients with stable renal function, including after treatment for subAR, potentially improving KT outcomes. The authors present data for a blood‐based gene expression profile that can be used to detect and monitor the treatment of subclinical rejection in patients following kidney transplantation. See Naesens's editorial on page 5.

The effects of underlying noncodified risks are unclear on the prognosis of patients with end-stage renal disease (ESRD). We aimed to evaluate the association of residential area life expectancy with outcomes and processes of care for patients with ESRD in the United States.

This retrospective analysis data from the Clinical Trials in Organ Transplantation study suggests that changes in eGFR within the first 2 years after transplantation, but not urinary chemokine CXCL9 and donor-reactive interferon gamma-(IFNg)-producing T cells, are associated with graft loss at 5 years.

The authors evaluate incidence, survival rates and volume of low performance centers with Bayesian, Old- and New-CMS criteria among US kidney transplant programs. The incidence of flagging and difference in observed and expected outcomes are significantly different by performance criteria.

Purpose Ex vivo perfusion of marginal kidney grafts offers the chance to expand the donor pool, but there is no current clinical standard for the prolonged warm perfusion of renal grafts. This exploratory pilot study seeks to identify a stable ex vivo kidney perfusion model that can support low intravascular resistance and preserve histologic architecture in a porcine donation after cardiac death (DCD) model.Methods 15 kidneys were preserved in 1 of 3 settings: normothermic whole blood (NT-WB), normothermic Steen Solution™(XVIVO Perfusion) with whole blood (NT-Steen/WB), or subnormothermic Steen Solution™at 21°C (SNT-Steen). Kidneys were primarily assessed using hemodynamic parameters and histologic analysis.Results NT-WB perfusion resulted in high vascular resistance and glomerular necrosis. NT-Steen/WB and SNT-Steen resistance ranged between 0.18–0.45 mmHg/mL per minute and 0.25–0.53 mmHg/mL per minute, respectively, enabling stable perfusion for up to 24 hours. NT-Steen/WB demonstrated tubular and glomerular necrosis, while the histologic architecture of SNT-Steen was preserved with the exception of numerous proteinaceous casts.Conclusions Our results suggest that ex vivo kidney perfusion with Steen Solution™at 21°C supports low and stable vascular resistance and provides adequate histologic preservation during 24-hour perfusion.

Even among ostensibly healthy adults, there is often mild pathology in the kidney. The detection of kidney microstructural variation and pathology by imaging and the clinical pattern associated with these structural findings is unclear.

Approximately 59 000 kidney transplant candidates have been removed from the waiting list since 2000 for reasons other than transplantation, death, or transfers. Prior studies indicate that low‐performance (LP) center evaluations by the Scientific Registry of Transplant Recipients (SRTR) are associated with reductions in transplant volume. There is limited information to determine whether performance oversight impacts waitlist management. We used national SRTR data to evaluate outcomes of 315 796 candidates on the kidney transplant waiting list (2007–2014). Compared to centers without LP, rates of waitlist removal (WLR) were higher at centers with LP evaluations (44.6/1000 follow‐up years, 95% confidence interval [CI] 44.0, 45.1 versus 68.0/1000 follow‐up years, 95% CI 66.6, 69.4), respectively, which was consistent after risk adjustment (adjusted hazard ratio [AHR] = 1.59, 95% CI 1.55, 1.63). Candidate mortality following waitlist removal was lower at LP centers (AHR = 0.90, 95% CI 0.87, 0.94). Analyses limited to LP centers indicated a significant increase in WLR (+28.6 removals/1000 follow‐up years, p < 0.001), a decrease in transplant rates (−11.9/1000 follow‐up years, p < 0.001) and a decrease in mortality after removal (−67.5 deaths/1000 follow‐up years, p < 0.001) following LP evaluation. There is a significant association between LP evaluations and transplant center processes of care for waitlisted candidates. Further understanding is needed to determine the impact of performance oversight on transplant center quality of care and patient outcomes. This study demonstrates a signifi cant association between kidney transplant center waitlist management processes of care and performance oversight, including an increase in waitlist candidate removals among centers evaluated as low performers.

All living kidney donor candidates undergo evaluation of GFR. Guidelines recommend measured GFR (mGFR), using either an endogenous filtration marker or creatinine clearance, rather than estimated GFR (eGFR), but measurement methods are difficult, time consuming and costly. We investigated whether GFR estimated from serum creatinine (eGFRcr) with or without sequential cystatin C is sufficiently accurate to identify donor candidates with high probability that mGFR is above or below thresholds for clinical decision making. We combined the pretest probability for mGFR thresholds <60, <70, ≥80, and ≥90 mL/min per 1.73 m2based on demographic characteristics (from the National Health and Nutrition Examination Survey) with test performance of eGFR (categorical likelihood ratios from the Chronic Kidney Disease Epidemiology Collaboration) to compute posttest probabilities. Using data from the Scientific Registry of Transplant Recipients, 53% of recent living donors had predonation eGFRcr high enough to ensure ≥95% probability that predonation mGFR was ≥90 mL/min per 1.73 m2, suggesting that mGFR may not be necessary in a large proportion of donor candidates. We developed a Web‐based application to compute the probability, based on eGFR, that mGFR for a donor candidate is above or below a range of thresholds useful in living donor evaluation and selection. In this article, the authors evaluate the accuracy of estimated GFRcompared to measured GFRfor evaluation of candidates for living kidney donation, and provide a website for using creatinine and cystatin C to compute estimated GFRand its accuracy.

Previous studies suggest that quantifying donor‐reactive memory T cells prior to kidney transplantation by interferon gamma enzyme‐linked immunosorbent spot assay (IFNγELISPOT) can assist in assessing risk of posttransplant allograft injury. Herein, we report an analysis of IFNγELISPOT results from the multicenter, Clinical Trials in Organ Transplantation‐01 observational study of primary kidney transplant recipients treated with heterogeneous immunosuppression. Within the subset of 176 subjects with available IFNγELISPOT results, pretransplant IFNγELISPOT positivity surprisingly did not correlate with either the incidence of acute rejection (AR) or estimated glomerular filtration rate (eGFR) at 6‐ or 12‐month. These unanticipated results prompted us to examine potential effect modifiers, including the use of T cell‐depleting, rabbit anti‐thymocyte globulin (ATG). Within the no‐ATG subset, IFNγELISPOTnegsubjects had higher 6‐ and 12‐month eGFRs than IFNγELISPOTpossubjects, independent of biopsy‐proven AR, peak PRA, human leukocyte antigen mismatches, African‐American race, donor source, and recipient age or gender. In contrast, IFNγELISPOT status did not correlate with posttransplant eGFR in subjects given ATG. Our data confirm an association between pretransplant IFNγELISPOT positivity and lower posttransplant eGFR, but only in patients who do not receive ATG induction. Controlled studies are needed to test the hypothesis that ATG induction is preferentially beneficial to transplant candidates with high frequencies of donor‐reactive memory T cells. Analysis of data from the Clinical Trials in Organ Transplantation‐01 study associates a positive pretransplant donor‐reactive ELISPOT assay for interferon gamma with low posttransplant glomerular filtration rate, but only in patients who do not receive T cell‐depleting induction therapy with rabbit anti‐thymocyte globulin.

Follow‐up care for living kidney donors is an important responsibility of the transplant community. Prior reports indicate incomplete donor follow‐up information, which may reflect both donor and transplant center factors. New UNOS regulations require reporting of donor follow‐up information by centers for 2 years. We utilized national SRTR data to evaluate donor and center‐level factors associated with completed follow‐up for donors 2008–2012 (n = 30 026) using multivariable hierarchical logistic models. We compared center follow‐up compliance based on current UNOS standards using adjusted and unadjusted models. Complete follow‐up at 6, 12, and 24 months was 67%, 60%, and 50% for clinical and 51%, 40%, and 30% for laboratory data, respectively, but have improved over time. Donor risk factors for missing laboratory data included younger age 18–34 (adjusted odds ratio [AOR] = 2.03, 1.58–2.60), black race (AOR = 1.17, 1.05–1.30), lack of insurance (AOR = 1.25, 1.15–1.36), lower educational attainment (AOR = 1.19, 1.06–1.34), >500 miles to center (AOR = 1.78, 1.60–1.98), and centers performing >40 living donor transplants/year (AOR = 2.20, 1.21–3.98). Risk‐adjustment moderately shifted classification of center compliance with UNOS standards. There is substantial missing donor follow‐up with marked variation by donor characteristics and centers. Although follow‐up has improved over time, targeted efforts are needed for donors with selected characteristics and at centers with higher living donor volume. Adding adjustment for donor factors to policies regulating follow‐up may function to provide more balanced evaluation of center efforts. This study demonstrates significant variation in living kidney donor follow‐up information explained by donor characteristics and individual transplant centers that has important implications for interventions to improve follow‐up as well as for evaluating center compliance with UNOS regulations.

This study identifies a potential hole in the estimated posttransplant survival score that will affect preemptively listed candidates in the new adult kidney allocation policy.