Scott Gregory Westphal

Background. Living kidney donor transplantation provides recipients with kidney failure with an excellent graft function and survival. Donation of a kidney entails a thorough medical and psychosocial evaluation. Obesity is an increasingly prevalent medical condition and a known risk factor for the development of chronic kidney disease post-donation. Accepting overweight and obese individuals as living kidney donors remains controversial. The purpose of this study was to review the impact of obesity on the determination of candidates for living kidney donation at a single transplant center. Methods. We performed a retrospective chart review of living kidney donors evaluated over 5 years from January 1, 2019, to June 23, 2024 (n = 375). Data collected included donor demographics, lab testing, and health data, including body mass index (BMI), and weight loss interventions for those identified with a BMI ≥ 32 or a BMI ≥ 30-31.9 with medical comorbidities. Data analysis included descriptive statistics comparing approved versus declined donor candidates and interventions for weight loss if required. Results. A total of 375 individuals were invited for in-person evaluation for donation, of which 155 (41.3%) were declined. Key reasons for declination included medical co-morbidities (n = 73; 47%), psychosocial factors (n = 14; 9.2%), and elevated BMI (n = 22; 14%) as either primary or secondary reasons. Of the 22 obese individuals evaluated, nearly all had a consultation with our dietitian, with additional interventions recommended. Of those approved for donation, 13.2% required additional weight loss, with 100% (n = 29) receiving nutrition consults and some requiring weight loss medications. Conclusion. Candidacy for living kidney donation is in part dependent on BMI, along with other co-existing factors. Weight loss interventions included primarily a dietitian consultation, as well as diet and exercise, with infrequent use of GLP-1 agonists likely related to the timeframe of the study. These results should inform protocolized management of living donor candidates with obesity.

Introduction: OPTN Policy 3.7D, implemented January 5, 2023, mandates that all kidney transplant programs modify waiting time for candidates affected by race‐inclusive eGFR calculations. We report the early impact of this policy change.Methods: Our transplant program reviewed all listed transplant candidates and identified patients potentially eligible for waiting time modification. Eligible candidates received waiting time modification after submission of supporting evidence to the OPTN. We reviewed the impact on waiting time and transplant activity through October 1, 2023.Results: Forty‐six adult patients on our center's active waiting list self‐identified as Black/African American. 25 (54.3%) candidates qualified for waiting time modification. A median 451 (321, 1543.5) additional days of waiting time was added for qualifying patients. Of the 25 patients who qualified for waiting time modification, 11 patients received a deceased donor kidney in the early period following waiting time modification, including 5 patients transplanted within 1 month after modification.Conclusions: Policy 3.7D is one of few national mandates to address specifically structural racism within transplantation. Implementation has yielded near immediate effects with greater than 40% of time‐adjusted patients at our center receiving a deceased donor kidney transplant in the initial months after policy enactment. Early assessment demonstrates great potential impact for this policy.

Background: Effects of kidney injury (KI) at the time of liver transplantation (LT) for acute liver failure (ALF) remain poorly described. We hypothesized that patients with ALF and KI who undergo LT have persistent post‐transplant KI, inferior survival, and increased rate of kidney transplantation (KT).Methods: The US Scientific Registry of Transplant Recipients database was queried for patients transplanted with status 1 listing for LT between 2002 and 2021. KI was defined as estimated glomerular filtration rate (eGFR) ≤ 30 mL/min/1.73 m² or dialysis in the week prior to LT. Outcomes evaluated were post‐LT eGFR, listing for subsequent KT, and overall survival (OS) after LT.Results: A total of 2984 patients underwent LT for ALF with 1241 (41.6%) having KI. KI patients had lower eGFR at 6 months post‐LT (57.8 vs. 68.7, p < .001) that persisted out to 5 years (59.9 vs. 69.7, p < .001). KI patients were more likely to be listed for KT (4.3% vs. 1.9%, p < .001) and undergo listing sooner after LT (.8 vs. 3.7 years, p < .001). Patients without KI had higher adjusted post‐transplant OS compared to those with KI (HR .75, p < .001).Conclusion: KI in the setting of ALF portends a worse prognosis for both kidney recovery and OS.

Background: Kidney transplant is the best treatment for end‐stage renal disease (ESRD); however, access is limited by severe organ shortage. Public Health Service increased risk donors (PHS‐IRD) represent a significant portion of available organs which are discarded at disproportional rates.Methods: Pediatric nephrologists were surveyed regarding PHS‐IRD kidneys to understand attitudes and perceived barriers to the use of these grafts in children. We sought to elucidate what methods may help increase the likelihood of PHS‐IRD acceptance.Results: Twenty‐two responses were received from United States pediatric nephrologists representing 11 UNOS regions (response rate 5.9%). Of respondents, 50% had been practicing for 20+ years, 77% in academic hospitals, and 63% in cities with over 1 000 000 people. All respondents worked in an institution with a kidney transplant program. 41% reported that they would not accept PHS‐IRD kidneys under any circumstance, 45% would accept depending on the candidate's medical status, and 14% routinely accepted PHS‐IRD kidneys. Infectious transmission was the biggest disincentive reported (59%), with only 55% of respondents feeling comfortable counseling families on the associated risks. 82% of respondents did not perceive all PHS‐IRD as the same, and 90% supported stratifying PHS‐IRD into tiers based on risk, which would increase the likelihood of organ acceptance (82%) and assist in counseling families (91%).Conclusions: With improved utilization, PHS‐IRD kidneys offer a step toward decreasing the organ shortage. These findings suggest hesitance in use of PHS‐IRD kidneys for pediatric recipients. Further stratification of risk could aid in provider organ acceptance and counseling patients.