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• W1992964063 abstract "Living donors supply approximately 40% of renal allografts in the United States. Based on current data, perioperative mortality after donor nephrectomy is approximately 3 per 10,000 cases, and major and minor perioperative complications affect approximately 3% to 6% and 22% of donors, respectively. Donor nephrectomy does not appear to increase long-term mortality compared with controls, nor does it appear to increase ESRD risk among white donors. Within the donor population, the likelihood of postdonation chronic renal failure and medical comorbidities such as hypertension and diabetes appears to be relatively higher among some donor subgroups, such as African Americans and obese donors, but the impact of uninephrectomy on the lifetime risks of adverse events expected without nephrectomy in these subgroups has not yet been defined. As national follow-up of living donors in the United States is limited in scope, duration, and completeness, additional methods for quantifying risk among diverse living donors are needed. In addition to improved national collection of follow-up data, possible sources of information on donor outcomes may include focused studies with carefully defined control groups, and database integration projects that link national donor registration records to other data sources. Given the growth and evolving characteristics of the living donor population, as well as changes in surgical techniques, tracking of short- and long-term risks after living kidney donation is vital to support truly informed consent and to maintain public trust in living donation. The transplant community must persist in their efforts to accurately assess risk across demographically diverse living kidney donors. Living donors supply approximately 40% of renal allografts in the United States. Based on current data, perioperative mortality after donor nephrectomy is approximately 3 per 10,000 cases, and major and minor perioperative complications affect approximately 3% to 6% and 22% of donors, respectively. Donor nephrectomy does not appear to increase long-term mortality compared with controls, nor does it appear to increase ESRD risk among white donors. Within the donor population, the likelihood of postdonation chronic renal failure and medical comorbidities such as hypertension and diabetes appears to be relatively higher among some donor subgroups, such as African Americans and obese donors, but the impact of uninephrectomy on the lifetime risks of adverse events expected without nephrectomy in these subgroups has not yet been defined. As national follow-up of living donors in the United States is limited in scope, duration, and completeness, additional methods for quantifying risk among diverse living donors are needed. In addition to improved national collection of follow-up data, possible sources of information on donor outcomes may include focused studies with carefully defined control groups, and database integration projects that link national donor registration records to other data sources. Given the growth and evolving characteristics of the living donor population, as well as changes in surgical techniques, tracking of short- and long-term risks after living kidney donation is vital to support truly informed consent and to maintain public trust in living donation. The transplant community must persist in their efforts to accurately assess risk across demographically diverse living kidney donors. Clinical Summary•Donor nephrectomy does not appear to increase long-term mortality compared with controls, nor does it appear to increase ESRD risk among white donors.•Within the donor population, the likelihood of postdonation CKD, ESRD, and medical comorbidities is relatively higher among some donor subgroups, such as African Americans and obese donors.•The impact of uninephrectomy on the lifetime risks of adverse renal and medical outcomes expected without nephrectomy has not yet been defined across subgroups.•Attempts to delineate lifetime risks of adverse events after living donation in relation to factors such as donor age, race, obesity, and family history warrant ongoing attention. •Donor nephrectomy does not appear to increase long-term mortality compared with controls, nor does it appear to increase ESRD risk among white donors.•Within the donor population, the likelihood of postdonation CKD, ESRD, and medical comorbidities is relatively higher among some donor subgroups, such as African Americans and obese donors.•The impact of uninephrectomy on the lifetime risks of adverse renal and medical outcomes expected without nephrectomy has not yet been defined across subgroups.•Attempts to delineate lifetime risks of adverse events after living donation in relation to factors such as donor age, race, obesity, and family history warrant ongoing attention. Living kidney donors (LKDs) reduce the growing gap between the demand for and supply of renal allografts, and offer their recipients the best opportunity for dialysis-free survival.1Terasaki P.I. Cecka J.M. Gjertson D.W. Takemoto S. High survival rates of kidney transplants from spousal and living unrelated donors.N Engl J Med. 1995; 333: 333-336Crossref PubMed Scopus (1070) Google Scholar Longer waiting times for deceased donor transplants, recognition that even poorly matched living donors’ kidneys provide good recipient outcomes, and increased use of minimally invasive surgical techniques for donor nephrectomy have stimulated growth in living kidney donation over the past 10 years.2Klein A.S. Messersmith E.E. Ratner L.E. Kochik R. Baliga P.K. Ojo A.O. Organ donation and utilization in the United States, 1999-2008.Am J Transplant. 2010; 10: 973-986Crossref PubMed Scopus (255) Google Scholar In the United States, the number of kidney transplants from living donors increased from fewer than 2000 in 1988, to 6276 in 2010, when living donors supplied 37% of renal allografts nationally.3OTPN/HRSA. National Data, Transplants by Donor Type. Available at: http://optn.transplant.hrsa.gov/latestData/rptData.asp. Accessed June 1, 2011.Google Scholar Despite increasing use of living donor organs to address the organ shortage, mandated follow-up of the health of living donors in the United States is limited in scope and duration. The Organ Procurement and Transplantation Network (OPTN) has collected follow-up data on living donors from participating transplant centers at 6 months and 1 year since 1999, including information on serum creatinine, blood pressure, and body mass index (BMI).4Brown Jr., R.S. Higgins R. Pruett T.L. The evolution and direction of OPTN oversight of live organ donation and transplantation in the United States.Am J Transplant. 2009; 9: 31-34Crossref PubMed Scopus (28) Google Scholar Data on requirements for medications to treat hypertension and diabetes were added in 2004, and the duration of follow-up was extended to 2 years in 2008. These donor follow-up polices contrast with national tracking of solid organ transplant recipients by the OPTN for the life of the allograft. Even with this limited reporting period, missing data are common on living donor follow-up forms submitted to the OPTN. In 2006, complications data were more than 50% incomplete at 1 year, and approximately one-third of LKDs were reported “lost to follow-up.”2Klein A.S. Messersmith E.E. Ratner L.E. Kochik R. Baliga P.K. Ojo A.O. Organ donation and utilization in the United States, 1999-2008.Am J Transplant. 2010; 10: 973-986Crossref PubMed Scopus (255) Google Scholar, 5Graham W. Living donor follow-up data: status report from the OPTN. Advisory Committee on Organ Transplantation (ACOT), Rockville, MD2008https://www.team-psa.com/DOT/ACOT2008/presentations.aspGoogle Scholar Emerging data also suggest that reporting rates are lower for donors who may have limited access to health care, such as those of nonwhite race or without health insurance.6Ommen ES, Lapointe Rudow D, Medapalli RK, Schroppel B, Murphy B. When good intentions are not enough: obtaining follow-up data in living kidney donors. Am J Transplant. In press.Google Scholar In this context, much of the information on long-term outcomes after living donation has been drawn from single-center, retrospective studies. Recently, data integration methods involving linkage of the OPTN registry to other information sources such as the Social Security Death Master File (SSDMF) and health insurance claims have been applied as a method for capturing information on large samples of previous donors beyond the OPTN-mandated reporting periods.7Segev D.L. Muzaale A.D. Caffo B.S. et al.Perioperative mortality and long-term survival following live kidney donation.JAMA. 2010; 303: 959-966Crossref PubMed Scopus (559) Google Scholar, 8Lentine K.L. Schnitzler M.A. Xiao H. et al.Racial variation in medical outcomes among living kidney donors.N Engl J Med. 2010; 363: 724-732Crossref PubMed Scopus (230) Google Scholar, 9Lentine KL, Schnitzler MA, Xiao H, et al. Associations of recipient illness history with hypertension and diabetes after living kidney donation. Transplantation. In press.Google Scholar As the optimal approach to capturing and analyzing health outcomes after living kidney donation undergoes increasing debate among the transplant community and regulatory bodies, it is worthwhile to consider the state of available evidence. In this article, we review currently available information on perioperative risks, long-term mortality, renal disease, and medical outcomes after living kidney donation, and consider needs for ongoing and improved assessment of health outcomes among living donors. According to OPTN reports for 51,113 LKDs between 1998 and 2008, 14 donor deaths (2.7 per 10,000) were reported by centers to the OPTN or identified in the SSDMF, and 39 donors (7.6 per 10,000) died within 12 months after donation.10Davis C.L. Cooper M. The state of U.S. living kidney donors.Clin J Am Soc Nephrol. 2010; 5: 1873-1880Crossref PubMed Scopus (77) Google Scholar Recent linkage of OPTN registration data for 80,347 living donors between 1994 and 2009 with the SSDMF by Segev and colleagues yielded a similar 90-day mortality estimate of 3.1 per 10,000 that did not change significantly over the 15-year study period (Table 1).7Segev D.L. Muzaale A.D. Caffo B.S. et al.Perioperative mortality and long-term survival following live kidney donation.JAMA. 2010; 303: 959-966Crossref PubMed Scopus (559) Google Scholar Surgical mortality was higher in men than women (5.1 vs 1.7 per 10,000), black versus white and Hispanic donors (7.6 vs 2.6 and 2.0 per 10,000, respectively), and donors with versus without baseline hypertension (36.7 vs 1.3 per 10,000).Table 1Summary of Recent Studies Examining Short- and Long-term Mortality Among LKDsReferenceLKD Participants and Data SourceComparison Data (if any)Outcome MeasuresFindings Within LKDsComparison of LKDs and Non-LKDsIbrahim and colleagues11Ibrahim H.N. Foley R. Tan L. et al.Long-term consequences of kidney donation.N Engl J Med. 2009; 360: 459-469Crossref PubMed Scopus (828) Google ScholarRetrospective cohort study of 3698 LKDs (98.8% white race) at a U.S. center between 1963 and 2007Age- and sex-specific life table estimates from the Human Mortality DatabaseDeath based on SSDMF records up to December 2007268 documented deathsCause of death identified in 106 (cardiovascular in 30%)LKD survival appeared similar to general population sample (statistical comparison not possible)Segev and colleagues7Segev D.L. Muzaale A.D. Caffo B.S. et al.Perioperative mortality and long-term survival following live kidney donation.JAMA. 2010; 303: 959-966Crossref PubMed Scopus (559) Google ScholarLinkage of OPTN data for 80,347 U.S. LKDs between 1994 and 2009 with SSDMFSample from NHANES III, matched by age, sex, race, education, smoking history, BMI, and systolic blood pressureSurgical mortality (within 90 days) based on SSDMF recordsLong-term death (up to 12 years) based on SSDMFSurgical mortality: 3.1 per 10,000 LKDsCorrelates of higher relative surgical mortality in LKDs: male sex, black race, baseline hypertension Correlates of higher relative long-term mortality in LKDs: older age, male sex, black race, baseline hypertensionLong-term LKD mortality not higher versus age- and comorbidity-matched controlsAbbreviations: LKD, living kidney donor; SSDMF, Social Security Death Master File; OPTN, Organ Procurement and Transplantation Network; NHANES, National Health and Nutrition Evaluation Survey; BMI, body mass index. Open table in a new tab Abbreviations: LKD, living kidney donor; SSDMF, Social Security Death Master File; OPTN, Organ Procurement and Transplantation Network; NHANES, National Health and Nutrition Evaluation Survey; BMI, body mass index. Early postoperative complications reported by centers to the OPTN within 6 weeks for 12,010 living donors between 2007 and 2008 indicated the need for blood transfusion in 0.4%, readmission in 2.1%, interventional procedures in 0.9%, and reoperation in 0.5%.10Davis C.L. Cooper M. The state of U.S. living kidney donors.Clin J Am Soc Nephrol. 2010; 5: 1873-1880Crossref PubMed Scopus (77) Google Scholar These are minimum estimates because more than 50% of source forms were submitted at less than 6 weeks after donation, and because centers, rather than donors, are the source of the reporting. Records from the Nationwide Inpatient Sample, an all-payer inpatient care database comprising a stratified sample of 20% of nonfederal U.S. hospitals from participating states, were also recently examined to quantify short-term complications after living donor nephrectomy.12Colombo B. Singla A. Li Y. et al.Current trends and short-term outcomes of live donor nephrectomy: a population-based analysis of the nationwide inpatient sample.World J Surg. 2010; 34: 2985-2990Crossref PubMed Scopus (6) Google Scholar Based on discharge information for 9437 patients who underwent donor nephrectomy between 1998 and 2006, the incidence of short-term complications considered major was 0.6%. The outcomes assessed were described as “common complications associated with high risk surgery,” such as pulmonary compromise (0.2%), deep venous thrombosis and/or pulmonary embolism (0.1%), reopening of the surgical site (0.1%), and gastrointestinal hemorrhage (0.1%), but the ascertainment algorithm was not further specified. In contrast, higher postoperative complication rates have been reported with application of a standardized classification algorithm in other studies, including analyses of a prospective registry and of hospital coding data. The Clavien grading system defines surgical complications involving an array of systems including cardiac, respiratory, neurological, gastrointestinal, renal, and other as “deviations from the ideal postoperative course,” and grades advancing severity by 5 levels according to treatment requirements.13Dindo D. Demartines N. Clavien P.A. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.Ann Surg. 2004; 240: 205-213Crossref PubMed Scopus (20972) Google Scholar A prospective national registry capturing data for 1022 living donor nephrectomies in Norway between 1997 and 2008 classified major complications as Clavien grade 3 events (ie, requiring radiological or surgical intervention) or higher, and minor as Clavien grade 1 or 2 events.14Mjoen G. Oyen O. Holdaas H. Midtvedt K. Line P.D. Morbidity and mortality in 1022 consecutive living donor nephrectomies: benefits of a living donor registry.Transplantation. 2009; 88: 1273-1279Crossref PubMed Scopus (87) Google Scholar By this method, the incidence of major and minor complications was 2.9% and 18%, respectively. There were no deaths. Clinical correlates of a combined end point of major complications, perioperative bleeding, and/or intraoperative incidents included laparoscopic compared with open approach (adjusted odds ratio [aOR]: 2.76), BMI of >30 (aOR: 1.76), right versus left kidney (aOR: 1.59), and renal vessel anomalies (aOR: 1.56). Higher risk with the laparoscopic approach was attributed to early generation equipment and the technical learning curve. Application of the Clavien system to University HealthSystem Consortium hospital coding data for 3074 living donation events at 28 U.S. centers between 2004 and 2005 identified an overall complications frequency of 10.6%, including major (Clavien grade ≥3) complications in 4.2%.15Patel S. Cassuto J. Orloff M. et al.Minimizing morbidity of organ donation: analysis of factors for perioperative complications after living-donor nephrectomy in the United States.Transplantation. 2008; 85: 561-565Crossref PubMed Scopus (58) Google Scholar Factors associated with increased risk of any complication included older donor age, obesity, tobacco use, and low center volume, although only annual center volume of <50 donor nephrectomy procedures was associated with increased risk of major complications. A retrospective chart review of laparoscopic urological procedures at a high-volume center, including 553 donor nephrectomies between 1993 and 2005, reported major and minor Clavien complications frequencies of 5.8% and 22%, respectively.16Permpongkosol S. Link R.E. Su L.M. et al.Complications of 2,775 urological laparoscopic procedures: 1993 to 2005.J Urol. 2007; 177: 580-585Abstract Full Text Full Text PDF PubMed Scopus (214) Google Scholar Thus, in contrast with the relatively low frequency of complications within 6 weeks of donation identified by OPTN reporting, major complications in 3% to 6% and minor complications in up to 22% during the nephrectomy hospitalization have been identified using the Clavien system. These data highlight the importance of surveillance of postoperative complications after kidney donation by standardized methods such as prospective registries and/or coordinated assessments of hospital claims data using established grading systems. Attention to patients with higher-risk clinical features, the impact of evolving surgical techniques, and the role of center experience and volume should be considered in the surveillance and evaluation of short-term complications after living donation. As the OPTN collects living donor follow-up information for only 2 years, data on donor mortality beyond the perioperative period have generally been drawn from retrospective, single-center studies that may be limited by loss to follow-up and selection biases.17Ommen E.S. Winston J.A. Murphy B. Medical risks in living kidney donors: absence of proof is not proof of absence.Clin J Am Soc Nephrol. 2006; 1: 885-895Crossref PubMed Scopus (80) Google Scholar A recent cohort study of 3698 donors at the University of Minnesota that achieved high ascertainment of long-term patient and renal survival status found no adverse impacts of living kidney donation on life span compared with general population life table estimates from the Human Mortality Database (Table 1).11Ibrahim H.N. Foley R. Tan L. et al.Long-term consequences of kidney donation.N Engl J Med. 2009; 360: 459-469Crossref PubMed Scopus (828) Google Scholar This cohort was racially homogenous, with 98.8% white race participants. Linkage of OPTN and SSDMF records for a large, national living donor sample recently identified higher relative mortality over 12 years among older compared with younger donors, men versus women (hazard ratio [HR]: 1.7, 95% confidence interval [CI]: 1.5-2.0), black versus white donors (HR: 1.3, 95% CI: 1.0-1.6), and donors with versus without baseline hypertension (HR: 1.7, 95% CI: 1.1-2.9).7Segev D.L. Muzaale A.D. Caffo B.S. et al.Perioperative mortality and long-term survival following live kidney donation.JAMA. 2010; 303: 959-966Crossref PubMed Scopus (559) Google Scholar However, long-term death rates did not exceed rates of matched control subjects from the National Health and Nutrition Evaluation Survey (NHANES).7Segev D.L. Muzaale A.D. Caffo B.S. et al.Perioperative mortality and long-term survival following live kidney donation.JAMA. 2010; 303: 959-966Crossref PubMed Scopus (559) Google Scholar The composition of reported deaths after kidney donation appears to differ from that in the general population. Cardiovascular disease (including stroke) comprises the leading cause of death in the general populations of many developed countries, including the United States and Japan.18Center for Disease Control and Prevention. Death and Mortality (U.S.). Available at: http://www.cdc.gov/nchs/fastats/deaths.htm. Accessed May 17, 2011.Google Scholar, 19World Health Organization. Mortality Country Fact Sheet 2006. Available at: http://www.who.int/whosis/mort/profiles/mort_wpro_jpn_japan.pdf. Accessed May 17, 2011.Google Scholar In contrast, recent OPTN and SSDMF data identified cancer as the most common cause of death within 7 years after kidney donation in the United States, accounting for 10.3% of deaths overall and 23.8% of deaths with a reported cause.10Davis C.L. Cooper M. The state of U.S. living kidney donors.Clin J Am Soc Nephrol. 2010; 5: 1873-1880Crossref PubMed Scopus (77) Google Scholar Among the 44% of deaths with reported causes, the next most common etiologies were cardiovascular disease (including heart attack, cerebral hemorrhage, and aneurysm) in 14.0%, motor vehicle accidents in 14.0%, and other accidents in 12.5%. Malignancy was the attributed cause of 43% deaths after kidney donation in a recent study of long-term living donor outcomes at a transplant center in Japan that included causes for all identified deaths,20Okamoto M. Akioka K. Nobori S. et al.Short- and long-term donor outcomes after kidney donation: analysis of 601 cases over a 35-year period at Japanese single center.Transplantation. 2009; 87: 419-423Crossref PubMed Scopus (87) Google Scholar followed by cerebrovascular disease in 11.3% and heart disease in 5.3%. The lower ranking of cardiovascular mortality among causes of donor death may in part reflect effective screening and exclusion of potential donors with advanced or intermediate cardiovascular risk factors at evaluation. However, given the high frequency of unknown causes in >50% of donor deaths the U.S. sample,10Davis C.L. Cooper M. The state of U.S. living kidney donors.Clin J Am Soc Nephrol. 2010; 5: 1873-1880Crossref PubMed Scopus (77) Google Scholar better tracking of the details of postdonation mortality is warranted. Recent studies examining renal outcomes among LKDs are described in Table 2. In addition to long-term ascertainment of donor mortality, ESRD was assessed among the 3698 living donors in the University of Minnesota cohort by reports of recipients and donors themselves. ESRD requiring dialysis or transplantation developed in 11 donors from this cohort at an average of 22.5 ± 10.4 years postdonation, yielding a rate of 180 cases per million per year, which did not exceed the national ESRD rate for white Americans of 268 cases per million per year.11Ibrahim H.N. Foley R. Tan L. et al.Long-term consequences of kidney donation.N Engl J Med. 2009; 360: 459-469Crossref PubMed Scopus (828) Google Scholar However, although only 45 of 3698 donors in the full cohort were nonwhite, 3 of 11 donors who developed ESRD were nonwhite.Table 2Summary of Recent Studies Examining Renal Outcomes Among LKDsReferenceLKD Participants and Data SourceComparison Data (if any)Outcome MeasuresFindings Within LKDsComparison of LKDs and Non-LKDsGibney and colleagues21Gibney E.M. King A.L. Maluf D.G. Garg A.X. Parikh C.R. Living kidney donors requiring transplantation: focus on African Americans.Transplantation. 2007; 84: 647-649Crossref PubMed Scopus (97) Google ScholarOPTN data living donor registrations and transplant waitlist registrations between 1993 and 2005N/ATransplant waitlist registrations in previous LKDs44% of 102 LKDs waitlisted after donation in the period were blackBlack LKDs comprised 14.3% of 8889 LKDs in the period, and were overrepresented among LKDs on the waitlist (P < .001)Ibrahim and colleagues11Ibrahim H.N. Foley R. Tan L. et al.Long-term consequences of kidney donation.N Engl J Med. 2009; 360: 459-469Crossref PubMed Scopus (828) Google ScholarRetrospective cohort study of 3698 LKDs at a U.S. center between 1963 and 2007United States Renal Data System, annual ESRD incidence ratesESRD based on report of the LKD or recipientGFR measured in 255 LKDESRD: 180 cases PMPYMeasured GFR: >60 mL/min/1.73 m2 in 85.5% of the subgroup with GFR dataESRD in LKDs did not exceed national ESRD rate for white Americans (268 cases PMPY)Lentine and colleagues8Lentine K.L. Schnitzler M.A. Xiao H. et al.Racial variation in medical outcomes among living kidney donors.N Engl J Med. 2010; 363: 724-732Crossref PubMed Scopus (230) Google ScholarLinkage of OPTN data for 4650 LKDs between 1987 and 2007 with administrative billing claims from a private health insurer (2000-2007 claims)Median time from donation to end of insurance: 7.7 yearsN/A for renal outcomesClaims-based diagnoses of CKDStage-specific coding examined a subgroup of 2307 with insurance benefits after start of stage-specific codingCKD diagnosis: Overall, 5.2% at 5 years. Approximately twice as likely among black (aHR: 2.32, P < .05) or Hispanic (aHR: 1.90, P < .05) compared with white LKDsCKD stage 3 or higher in subanalysis: more likely in black (aHR: 3.60, P = .009) or Hispanic (aHR: 4.23, P = .006) versus white LKDsDialysis-requiring CKD in subanalysis: 0.7% black (P = .02 vs white) and 0.5% Hispanic (P = .10) LKDs, versus 0 cases among white LKDsN/AAbbreviations: GFR, glomerular filtration rate; PMPY, per million per year; aHR, adjusted hazard ratio. Open table in a new tab Abbreviations: GFR, glomerular filtration rate; PMPY, per million per year; aHR, adjusted hazard ratio. Assessment of renal function measures captured in the OPTN survey for donors between 2000 and 2005 at an average of 5 months postdonation found no appreciable differences in serum creatine or eGFR levels among African American compared with white donors in this early assessment period.22Doshi M. Garg A.X. Gibney E. Parikh C. Race and renal function early after live kidney donation: an analysis of the United States Organ Procurement and Transplantation Network Database.Clin Transplant. 2010; 24: E153-E157Crossref PubMed Scopus (15) Google Scholar In contrast, recent queries of kidney transplant candidate registrations raised concerns for racial disparities in ESRD risk in the longer term after living donation. Although African Americans composed 12% of U.S. LKDs between 1996 and 2007, they represented 43% of 148 previous donors listed for kidney transplantation after donation.21Gibney E.M. King A.L. Maluf D.G. Garg A.X. Parikh C.R. Living kidney donors requiring transplantation: focus on African Americans.Transplantation. 2007; 84: 647-649Crossref PubMed Scopus (97) Google Scholar, 23Cherikh W.S. Pan-Yen F. Taranto S.E. Prior living kidney donors who were subsequently placed on the waiting list: an updated OPTN analysis.Am J Transplant. 2008; 8: 335Google Scholar ESRD also appeared to develop within a shorter time from donation among affected black donors, with a median time to reporting of 16 years compared with 21 years in white donors who developed ESRD. Lentine and colleagues recently linked OPTN records for 4650 living donors, including 13% black and 8% Hispanic donors, with administrative claims of a private health insurer.8Lentine K.L. Schnitzler M.A. Xiao H. et al.Racial variation in medical outcomes among living kidney donors.N Engl J Med. 2010; 363: 724-732Crossref PubMed Scopus (230) Google Scholar CKD was indicated as a medical diagnosis in the claims among 5.2% of donors by the fifth donation anniversary. Diagnosed CKD after nephrectomy was approximately twice as likely among black (adjusted hazard ratio [aHR]: 2.32, P < .05) or Hispanic (aHR: 1.90, P < .05) compared with white donors. Subanalysis of donors who had benefits in the studied insurance plan after the introduction of stage-specific billing codes for CKD indicated significantly increased risk of CKD stage 3 or higher diagnoses among donors who were black (aHR: 3.60, P = .009) or Hispanic (aHR: 4.23, P = .006) compared with white donors. CKD requiring dialysis was reported in 2 of 271 black (0.7%, P = .02 vs white) and 1 of 197 Hispanic (0.5%, P = .10 vs white) previous donors, compared with no cases among 1786 white donors. The time from donation to ESRD ranged from 6.3 to 16.5 years. Provocative new research has identified coding variants in the apolipoprotein L1 gene that are strongly associated with nondiabetic ESRD risk in African Americans in an autosomal recessive pattern of inheritance,24Genovese G. Friedman D.J. Ross M.D. et al.Association of trypanolytic ApoL1 variants with kidney disease in African Americans.Science. 2010; 329: 841-845Crossref PubMed Scopus (1459) Google Scholar such that the presence of 2 risk alleles has been associated with marked increase in the risk of deceased donor allograft loss at 1 center.25Reeves-Daniel A.M. Depalma J.A. Bleyer A.J. et al.The APOL1 gene and allograft survival after kidney transplantation.Am J Transplant. 2011; 11: 1025-1030Crossref PubMed Scopus (254) Google Scholar These data raise the possibility of genotyping as a future approach to risk-stratify African American potential living donors. Outside the United States, in a recent report of 8 donors at a center in Japan who developed CKD stage 5 or ESRD, the mean time from donation was 16 ± 3.2 years.26Kido R. Shibagaki Y. Iwadoh K. et al.How do living kidney donors develop end-stage renal disease?.Am J Transplant. 2009; 9: 2514-2519Crossref PubMed Scopus (40) Google Scholar In most cases, renal function was stable for a prolonged period but then suddenly declined with new initiating events or comor" @default.
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• W1992964063 title "Risks and Outcomes of Living Donation" @default.
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