A Financial Analysis of Elderly Kidney Transplant Recipients

Purpose: To compare and evaluate outcomes of for younger (Y) versus elderly (E) kidney transplant recipients (KTR) during the first year post-transplant. As the number of elderly KTR increases, differences between this population and younger are unknown. Methods: A single-center retrospective analysis of medical records of 318 first-time KTR from 2003-10 on mycophenolate, tacrolimus, and steroid regimen was performed. The study population was divided into two cohorts: (Y: \u3c59 yrs; n=172; E: \u3e65 yrs; n=146). KTR aged 60-64 were excluded to distinguish groups. Baseline characteristics, the number of readmissions post-transplant (RA), readmission lengths of stay (LOS), and the total follow-up costs of the first year post-transplant were analyzed. Reliability was tested using the Wilcoxon rank-sum test for the median comparisons between elderly and younger subjects\u27 number of readmissions, read-mission lengths of stay, and follow-up costs during the first year post-transplant. The chi-square test was used to test significance when readmission during the first year was tested as a binary variable (yes vs no). Results: Younger and elderly KTR had similar numbers of RA and LOS; however. elderly follow-up costs were significantly more than younger subjects. [Figure Presented] Conclusions: Elderly KTR appear to present a greater economic burden on hospital systems during the first year post-transplant due to the greater costs of care; however, with similar post-transplant rates of RA and LOS, the costs incurred may be related to comorbid health conditions rather than transplant-related follow-up. A more detailed analysis of the reasons for expensive hospitalizations post-transplant may be beneficial in determining the risk-benefit of transplanting elderly patients

How Much Does Graft Function Cost Us? A Financial Analysis of Delayed Graft Function in Kidney Transplant Recipients

Purpose: Kidney transplant recipients (KTR) who receive dialysis post-transplant experience worse outcomes during the first year post-transplant. Whether KTR discharged with elevated levels of serum creatinine but not receiving dialysis experience similar outcomes is unclear. Furthermore, the question of whether avoidance of dialysis among patients with elevated levels of serum creatinine can save money while achieving similar 1 year outcomes remains unanswered. Methods: A single-center retrospective analysis of the medical records of 345 first-time KTR from 2012-15 was performed. KTR received antithymocyte globulin (4. 5mg/kg), basihximab (20mg x2), or no induction based on immunological risk. KTR were maintained on a regimen of mycophenolate, tacrolimus, and steroids. To stratify patients with marginal graft function, three definitions of graft function were used to divide the study population: immediate (IGF, n=174), slow (SGF, n=83), and delayed (DGF, n=88). IGF is defined as Kill with a serum creatinine (SCr) \u3c3mg/dL; SGF as Kill with a SCr \u3e3mg/dL at post-operative day (POD) 5; and DGF as Kill requiring dialysis within the first 7 POD. Kill with IGF were excluded from this analysis and the other two groups were compared. Initial transplant hospitaliza-tion and readmissions for the first year post-transplant were analyzed including the incidence, length of stay, and cost. Serum creatinine (SCr) at discharge and eGFRs at 1 year were also collected. Readmissions related to the transplanted kidney such as acute kidney injury, hydronephrosis, or rejection were defined as graft-related. Non-graft related readmissions were defined as related to infection, cardiovascular. gastrointestinal, electrolyte disturbances, anemia, Surgery, or cancer. Results: Results are summarized in the table below. SCr at discharge for SGF was 4. 7 mg/dL (3. 76, 6. 45) and not reported for DGF due to HP. [Figure Presented] Conclusions: DGF presents a greater economic burden on hospital systems during the first year post-transplant. KTR with marginal kidney function without having dialysis experienced less and shorter readmissions as well as less graft-related readmissions. Furthermore, the follow-up charges are significantly less for these patients. Non-dialysis interventions to manage slow graft function may present a cost-benefit and should be considered in this specific population

Ethnic disparities in elderly patients receiving kidney transplantation

Purpose: Over the past 10 years, the number of elderly kidney transplant recipients has increased. This analysis evaluates whether the trend is equitable across ethnic groups. Methods: Data collected by the Organ Procurement and Transplantation Network was used to follow trends in kidney transplantation. The study population consisted of elderly patients aged 65 and older (E) transplanted between 2006-2016. Variables were stratified by ethnicity. Major ethnic groups were included [Caucasian (C), African American (AA), Hispanic (H), Asian (AI)]. Remaining ethnicities account for \u3c2% of population and were excluded. Age, gender, total waitlist removal, waitlist mortality, waitlist times, donor type (deceased, living), patients receiving transplants, KDPI\u3e85%, and education levels were analyzed. High education was defi ned as associates, bachelors, or graduate degree. Results: 31656 patients aged 65 and older received transplants between 2006-16. C received more transplants from living donors and their wait was less than other groups when the wait time was less than 5 years (p\u3c0.0001). When \u3e5 years, there was no difference among groups. There was no difference in watitlist mortality among groups (p\u3e0.05). There was no difference in the change of the waitlist proportions over the last ten years: C, AA, H, and AI maintain similar proportions (p\u3c0.05). Ethnic groups received a similar number of \u3e85% KDPI transplants over time (p\u3e0.05). C had the highest levels of education when compared to other ethnic groups (p\u3c0.0001). These disparities were not observed between genders in elderly patients (p\u3e0.05). However, there was a significant difference among ethnicities across years for the study population among transplanted C, AA, H, and AI (p\u3c0.0001, figure 1). A post-hoc pairwise comparison revealed that it was due to the change of C, while the relative ratio of AA, H, and AI were the same across years (p\u3c0.0001). (Figure presented) Conclusion: Elderly Caucasian patients are receiving more kidney transplants than any other ethnic group. They tend to have shorter wait times, receive more living donor transplants, and have higher levels of education. Increased awareness is needed to reduce this major disparity

Decreased long-term survival with antithymocyte globulin induction in elderly kidney transplant recipients

Purpose: Long-term consequences of immunosuppression on the elderly is still unclear. This data to evaluates long-term outcomes for younger (Y) versus elderly (E) kidney transplant recipients (KTR). Methods: A single-center retrospective analysis of 318 medical records from 2003-10 for KTR on mycophenolate, tacrolimus, and steroid regimen was performed. KTR received antithymocyte globulin (Thy: 4.5mg/kg), basiliximab (Sim: 20mg x2), or no induction based on immunological risk. KTR were divided into two cohorts: (Y: ≤59 yrs; n=172; E: ≥65 yrs; n=146). KTR aged 60-64 were excluded to distinguish groups. Graft and patient survival were demonstrated by Kaplan-Meier plots and reliability was tested using a multivariate Cox proportional-hazards model and log-rank test, controlled for induction, type of transplant, gender, and race. Death events were plotted along the follow-up (FU) period by COD. Results: There was no statistical difference between groups\u27 baseline characteristics, induction therapy, graft failure, or median FU days [Y, 2132 (1770, 2729); E, 2048 (1540, 2538); p\u3e0.05]. Y KTR have better survival than E (figure 1) (p\u3c0.001), especially those who received Thy (p\u3c0.001). In the CoxPH model, risk of mortality increased with age [2.169 (1.287, 3.656), p=0.004]. No difference in mortality was observed for Sim or No (p\u3e0.05). When stratified by COD, cancer and infection (Inf) tended to occur early, within the first 5 yrs of transplant. Cardiovascular events (CV) were more evenly distributed during the long-term FU. Conclusions: Despite similar long-term graft survival, patient survival significantly decreased among the elderly patients. Mortality strongly correlated with patients who received Thymo. These findings suggest a survival benefit with less severe immunosuppressive regimen, particularly induction therapy among the elderly

Long-term outcomes of graft function in elderly kidney transplant recipients

Purpose: To compare and evaluate 5-year outcomes of graft function for younger (Y) versus elderly (E) kidney transplant recipients (KTR). Introduction: As the number of elderly KTR increases, differences between this population and younger are unknown. Methods: A single-center retrospective analysis of medical records of 318 firsttime KTR from 2003-10 on mycophenolate, tacrolimus, and steroid regimen was performed. The study population was divided into two cohorts: (Y: ≤59 yrs; n=172; E: ≥65 yrs; n=146). KTR aged 60-64 were excluded to distinguish groups. Baseline characteristics, first biopsy-proven acute rejection (BPAR), estimated glomerular fi ltration rates (eGFR) at discharge and annually up to 5 yrs were analyzed. BPAR were graded using Banff schema (≥2A = severe). Time to BPAR was demonstrated using Kaplan-Meier plots (KM) and reliability was tested using a multivariate Cox proportional-hazards model and log-rank test. Results: There was no statistical difference between demographics, induction therapy, maintenance immunotherapy, type of transplant, immediate graft function, BMI, length of stay, or median follow-up days [Y, 2132 (1770, 2729); E, 2048 (1540, 2538); p\u3e0.05]. There was no difference in eGFR at yrs 0-5 (p\u3e0.05). BPAR is described in table 1. KM exhibit less and earlier BPAR among E [0.376 (0.23, 0.615), p\u3c0.001]. The log rank tests indicate time to BPAR are indeed different in Y and E (p\u3c0.001). (Figure presented) (Table presented) Conclusions: Elderly KTR experience less rejection in incidence and severity. These patients also maintain excellent long-term graft function that is comparable to younger KTR

A National Cohort Validation of Graft Outcomes of Elderly Kidney Transplant Recipients

Purpose: Previous analyses comparing elderly kidney transplant recipients (KTR) to younger KTR found that elderly patients suffered higher rates of mortality, less biopsy-proven acute rejection (BPAR), and similar graft survival. A national cohort of patients is presented to validate these results. As the number of elderly KTR increases, differences between this population and younger are unknown. Methods: A national retrospective analysis of records of 225021 from 2008-2017 was performed. The study population was divided into two cohorts: (Y:65 yrs; n=l 72942). KTR aged 60-64 were excluded to distinguish groups. Graft and patient survival were demonstrated by Kaplan-Meier plots and reliability was tested using a multivariate Cox proportional-hazards model and log-rank test. Rates of rejection at 6 months and 1 year post-transplant were compared and reliability was tested using the Chi-square test. The rate of antithymocyte globulin for induction therapy in each group was also collected. Results: Younger KTR were51 (46, 55)years oldandfollowedfor 1114(385, 2097) days. Elderly KTR were 68 (66, 71) years old and followed for 1063 (365, 1818) days. The overall survival probability is significantly higher in the younger group. The CoxPH models show the younger group has a hazard ratio of 0. 36 (

Long-term outcomes among slow versus delayed or immediate graft function kidney transplant recipients: A single-center experience

Purpose: To compare and evaluate short and long-term outcomes for kidney transplant recipients (KTR) with slow graft function (SGF) versus delayed (DGF) or immediate (IGF) graft function. Introduction: KTR who experience DGF exhibit worse outcomes than other KTR; however there is a subset of patients who do not require dialysis post-transplant, but have slower graft recovery. This novel analysis provides new data on outcomes for this sub-population. Methods: A single-center retrospective analysis of medical records of 352 KTR from 2012-2015 was performed. Study population was divided into three cohorts: IGF (n=174), SGF (n=83), and DGF (n=95). IGF is defined as KTR with a serum creatinine (SCr) \u3c3mg/dL; SGF is defined as KTR with a SCr ≥3mg/dL at postoperative day (POD) 5; and DGF is defined as a KTR requiring dialysis within the first 7 POD. All African Americans (AA), KTR of ECD/DCD kidneys, repeat kidney transplants, and cPRA\u3e20% received thymo induction. Demographics, 1yr biopsy-proven rejection (BPAR), as well as SCr and eGFR at point of last follow-up (FU) post-transplant were analyzed. Results: There was no overall statistical difference between the three groups\u27 genders or ages. For other results, please refer to Table 1 (Table presented). DGF and SGF had a similar number of patients who received thymo induction (DGF, 64.21%; SGF, 67.47%; p\u3e0.05), but both statistically higher than IGF (44.83%; p\u3c0.05). In addition, DGF and SGF also had similar rates of BPAR at 1yr (DGF, 11.59%; SGF, 9.64%; p\u3e0.05), but both statistically higher than IGF (8.05%; p\u3c0.05). Conclusion: In our analysis, we found that the SGF patients behaved similarly to the DGF than the IGF population, long-term. Therefore, consideration must be made to these potentially high-risk patients

Association of body mass index of kidney transplant recipients with graft function post-transplant

Purpose: Obese kidney transplant recipients (KTR) are known to have a significantly higher risk of delayed graft function; however, there is no data on patients who have slow graft function (SGF) and do not require dialysis post-transplant. This analysis studies association of BMI and SGF. Methods: A single-center retrospective analysis of medical records of 352 KTR from 2012-15 was performed. Study population was divided into cohorts: immediate (IGF, n=174), slow (SGF, n=83), and delayed (DGF, n=95). IGF is defined as KTR with a serum creatinine (SCr) \u3c3mg/dL; SGF as KTR with a SCr ≥3mg/dL at postoperative day (POD) 5 not requiring dialysis; and DGF as KTR requiring dialysis within the first 7 POD. KTR received antithymocyte globulin (4.5mg/kg), basiliximab (20mg x2), or no induction based on immunological risk. BMI is measured as a continuous variable at the time of transplant. Logistic regression was used to study the association of BMI and graft function (GF) adjusted for age, induction therapy, type of transplant, donor SCr, gender, race, cPRA, transplant hospital LOS, and ICU admission. Follow-up charges ($K) for the first year of transplant and odds ratio are presented. Results: With each 1kg/m2, the odds of IGF (instead of DGF) decrease by 2% (p\u3c0.001), the odds of SGF (instead of IGF) increase by 1% (p\u3c0.05), and the odds of DGF (instead of SGF) increase by 2% (p\u3c0.05). These findings were corroborated by all subgroup analyses. IGF, SGF, and DGF groups were followed for 1062 (664, 1460), 1047 (726, 1368), and 866 (497, 1235), respectively (p\u3e0.05). SCr were higher at FU for SGF than IGF [1.45 (1.18, 1.95); 1.3 (1.01, 1.54); p\u3c0.001]. Overall cost at follow-up was greater for SGF than IGF [227 (201, 256); 193 (165, 248); p\u3c0.001]. (Table Presented) Conclusion: There is a strong relationship between BMI at baseline and graft function post-transplant among KTR. Any modest increase in BMI results in decreased GF and increases in overall medical costs of transplantation. KTR with normal BMI still experience SGF

Multivariate Cox proportional hazards model for estimating long-term risk of aging kidney transplant recipients.

Purpose: The growing number of elderly kidney transplant recipients (KTR) presents an opportunity to analyze and predict long-term outcomes and risk in this aging population. Methods: A single-center retrospective analysis of medical records from 2003-10 for KTR aged 40-79 on mycophenolate, tacrolimus, and steroid regimen was performed. Baseline variables including age, induction therapy, type of transplant, gender, and race were included in the multivariate Cox proportional hazards (PH) model for mortality, biopsy-proven acute rejection (BPAR), and graft failure (GF). Linear combination of model predictors weighted by regression coefficients in Cox PH model were used as a risk score for events. An optimal cut-off point was selected to classify patients into low vs high groups whereby the log-rank test statistic contrasting the groups would be maximized. Kaplan-Meier (KM) curves and log-rank test were used to assess the survival profiles. Results: 318 KTR were reviewed with median follow-up of 2120 days. Older age is associated with increased hazard ratio (HR) for mortality [1.04 (1.01, 1.06), p=0.003] and decreased HR for BPAR [0.96 (0.94, 0.98), p\u3c0.001], but not associated with GF. KM plots reveal low and high risk groups defi ned by fitted Cox PH models have significant separation (p\u3c0.001) for survival and BPAR. Other findings are increased HR for BPAR for recipients of living unrelated donors [2.23 (1.04, 4.82), p=0.04] vs living related donors and African Americans [1.79 (1.11, 2.92), p=0.02] vs Caucasians. Females experienced decreased HR [0.52 (0.33, 0.83), p=0.01] vs males for BPAR. (Figure presented) Conclusion: The predictive model for KTR informs clinicians of the risks of transplanting an aging population. For every year that age increases, KTR have a lower risk of experiencing BPAR, but a greater risk of mortality

Long-term preservation of renal function in liver transplant recipients with rabbit anti-thymocyte globulin induction and delayed initiation of calcineurin inhibitors

Methods: A single-center retrospective analysis of medical records of 989 liver transplant recipients from 2001-2010 were reviewed and evaluated for patients who received thymo induction with delayed initiation of CNI. All patients received mycophenolate mofetil (500mg BID) and steroids (x3 months post-livert ransplant). Results: Of 989 liver transplant recipients reviewed, 312 received thymo induction with delayed initiation of CNI. Median follow-up period was 839±629.12 (±SD) days post-liver transplant. Results are reported in Tables 1 and 2 (Table presented). In conclusion, in our analysis, we found that thymo induction with delayed initiation of CNI therapy in liver transplant patients is safe and associated with long-term improvements in renal function