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Biomedical subjects

Bertram L Kasiske

Publications and source records attributed to Bertram L Kasiske.

At least 19 recordsLinked to original sources
PubMed2006

Transplant tourism: Outcomes of United States residents who undergo kidney transplantation overseas.

BACKGROUND: Although international commerce in kidney transplantation is a reality, little is known about U.S. residents who travel abroad for kidney transplantation. METHODS: We retrospectively reviewed the clinical outcomes of patients who were evaluated at the University of Minnesota Medical Center or Hennepin County Medical Center, but then surreptitiously underwent kidney transplantation overseas. RESULTS: We identified 10 patients who underwent kidney transplantation outside the United States between September 16, 2002 and June 30, 2006 and then returned for care in our programs. Eight were transplanted in Pakistan (all Somali), one was transplanted in China (Chinese), and one was transplanted in Iran (Iranian). All but one had a living donor. Mean age was 36.8+/-12.5 years with median follow-up of 2.0 years (range 0.4-3.7). Three patients communicated their intent to travel abroad before transplantation. Induction immunosuppressive therapy (if any) was available in 3/10, and initial maintenance immunosuppression was known in 5/10. Complications were primarily infectious, with six potentially life-threatening infections in four patients. At last follow-up, mean serum creatinine was 1.13+/-0.34 mg/dL, acute rejection occurred in 2/10, 1/10 grafts failed due to acute rejection, and 9/10 patients were alive. CONCLUSIONS: Kidney function and graft survival were generally good after surreptitious overseas kidney transplantation. Major problems included incomplete perioperative information communicated to the posttransplant care facility and a high incidence of posttransplant infections. Longer follow-up and detailed cost analysis are needed to better understand the implications of the growing phenomenon of transplant tourism.

Adult↗
PubMed2006

Peripheral arterial disease and renal transplantation.

It was hypothesized that peripheral arterial disease (PAD) is less frequent after kidney transplantation than among comparable patients who are on the deceased-donor waiting list. The cumulative incidences and risk factors for PAD were compared among 43,427 adult transplant recipients and 53,309 adults who were placed on the renal transplant waiting list between 1995 and 2003. All patients had Medicare primary insurance coverage, and Medicare claims were used to identify PAD. For patients with diabetes, the 3-yr cumulative incidence of de novo PAD was 24% on the waiting list versus 20% after transplantation. For patients without diabetes, the 3-yr cumulative incidence was 9% on the waiting list versus 5% after transplantation. The adjusted relative risk (RR) for PAD among patients without diabetes was 0.73 (95% confidence interval [CI] 0.66 to 0.80; P < 0.0001) in the transplant population versus the waiting list population, whereas among patients with diabetes, it was 0.88 (95% CI 0.82 to 0.96; P = 0.0024). A diagnosis of PAD on the waiting list was associated with an almost three-fold increase in the RR for death for patients without diabetes (2.98; 95% CI 2.71 to 3.27; P < 0.0001) and with diabetes (2.92; 95% CI 2.71 to 3.15; P < 0.0001). After transplantation, de novo PAD increased the RR for death almost two-fold in patients without diabetes (1.92; 95% CI 1.63 to 2.26; P < 0.0001) and with diabetes (1.83; 95% CI 1.58 to 2.12; P < 0.0001). The incidence of PAD is higher on the waiting list than after transplantation and is associated with an increased risk for death among patients with and without diabetes.

Adolescent↗
PubMed2006

Acute myocardial infarction and kidney transplantation.

Although the risk for acute myocardial infarction (AMI) is lower after transplantation than on the waiting list, this risk may vary by patient population and may be different early versus late after transplantation. Risk factors for AMI were examined among 53,297 Medicare beneficiaries who were placed on the deceased-donor waiting list in 1995 to 2002. Early ( 3 mo) effects of receiving a deceased- or living-donor kidney transplant were examined using time-dependent covariates in Cox nonproportional hazards analysis. Overall, transplantation was associated with a 17% lower adjusted risk for AMI (0.83; 95% confidence interval [CI] 0.77 to 0.90) versus the waiting list. However, the relative risk (versus the waiting list) for AMI was greater for deceased- compared to living-donor transplants, with both being much greater early (deceased-donor 3.57 [95% CI 3.21 to 3.96] compared to living-donor 2.81 [95% CI 2.31 to 3.42]) than late (deceased-donor 0.45 [95% CI 0.41 to 0.50] compared to living-donor 0.39 [95% CI 0.33 to 0.47]) posttransplantation. Individuals who were >or=65 yr of age had a much higher risk (versus 18- to 34-yr-olds) for AMI early posttransplantation (8.01; 95% CI 5.12 to 12.53) compared with the waiting list (3.68; 95% CI 3.98 to 4.54) or late posttransplantation (4.37; 95% CI 3.07 to 6.20). Black patients had less reduction in AMI risk (versus white patients) late posttransplantation (0.78; 95% CI 0.64 to 0.95) compared with early posttransplantation (0.60; 95% CI 0.48 to 0.74) or on the waiting list (0.62; 95% CI 0.56 to 0.68). The AMI risk that was associated with chronic kidney disease from diabetes (versus glomerulonephritis) was relatively greater on the waiting list (1.64; 95% CI 1.45 to 1.85) compared with early (1.34; 95% CI 1.08 to 1.68) and late (1.39; 95% CI 1.12 to 1.72) posttransplantation. Thus the risk reduction for AMI with transplantation versus the waiting list varies by patient population and time after transplantation.

Adolescent↗
PubMed2006

An assessment of statin safety by nephrologists.

Recently, concerns regarding potential adverse effects of the statins on the kidney have been raised. The Kidney Expert Panel of the National Lipid Association's (NLA) Safety Task Force, made up of 3 nephrologists, was convened to review all of the currently available evidence pertinent to determining whether statins cause kidney injury, independent of the known, rare mechanisms of rhabdomyolysis and allergic, drug-induced, interstitial nephritis. The Panel reviewed published and unpublished evidence and found none that suggested that statins, when used in doses currently approved by the US Food and Drug Administration (FDA), cause kidney injury.

Dose-Response Relationship, Drug↗
PubMed2005

Persistent, asymptomatic, microscopic hematuria in prospective kidney donors.

BACKGROUND: Asymptomatic, microscopic hematuria is seen in 8-21% of the general population, has a good prognosis, and is generally not an indication for kidney biopsy. But whether it should preclude kidney donation is unclear. METHODS: Of 512 consecutive prospective donors, 14 (2.7%) continued to have asymptomatic, microscopic hematuria over 1 month. If the medical history, physical examination, and computerized tomographic angiography were unremarkable, and if they still wished to donate, a kidney biopsy was performed. RESULTS: In two prospective donors, hematuria resolved after treatment for urinary tract infection; two others declined donation and were referred to their primary care provider. Kidney biopsy in the remaining 10 showed: two normal; four thin basement membrane nephropathy (TBMN); one nonhomogeneous basement membrane abnormalities; one IgA nephropathy, 5 of 16 glomeruli globally sclerotic; one in a patient with a family history of Schimke's Syndrome, 7 of 30 glomeruli globally sclerotic; and one TBMN and early hypertensive changes without systemic hypertension. Only 4 of the 10 who underwent kidney biopsy donated (two normal, two TBMN). CONCLUSIONS: Kidney abnormalities are common in young, otherwise healthy, prospective kidney donor candidates with persistent, asymptomatic, microscopic hematuria. A kidney biopsy is often abnormal and aids in the decision-making process.

Adolescent↗
PubMed2005

Risk-stratified screening for ischemic heart disease in kidney transplant candidates.

BACKGROUND: Few studies have examined the effectiveness of a risk-stratified approach to screening kidney transplantation candidates for ischemic heart disease (IHD). METHODS: We retrospectively reviewed records from all adult patients (n = 514) placed on the deceased donor kidney transplantation waiting list at a single center between January 1992 and June 2000. During this time there was a consistent policy for high-risk patients to undergo noninvasive stress testing and/or coronary angiography. We examined screening tests, the resulting interventions, and the incidence of subsequent IHD events (myocardial infarction, angioplasty, bypass surgery, or IHD death) among those screened and not screened. RESULTS: For 224 (43.6%) low-risk patients who were not screened, the actuarial incidence of an IHD event after listing (before or after transplantation) was only 0.5% at 1 year, 3.5% at 3 years, and 5.3% at 5 years. Screening 290 (56.4%) high-risk patients resulted in prophylactic angioplasty in 18 (6.2%), and bypass surgery in 8 (2.8%) before listing. After listing, 61 patients were screened, resulting in angioplasty in 6 (9.8%) and bypass surgery in 1 (1.6%). Of the 68 patients who ultimately had an IHD event after being placed on the waiting list, only 13 (19.4%) had not been screened. CONCLUSIONS: A risk-stratified screening strategy effectively avoided unnecessary testing in 43.6%. However, the relatively low proportion of screened patients who underwent prophylactic angioplasty or bypass grafting raises the question of whether screening was effective in preventing IHD events.

Adolescent↗
PubMed2005

Dyslipidemias in patients who have chronic kidney disease.

Patients with CKD are at high risk for developing CVD. In fact, most CKD patients have a 10-year risk of coronary heart disease events greater than or equal to 20%, placing them in the highest risk category according to the National Cholesterol Education Program Adult Treatment Panel III guidelines. For this reason, the National Kidney Foundation K/DOQI guidelines for managing dyslipidemia suggest that CKD patients with LDL greater than or equal to 100 mg/dL (2.59 mmol/L) should be treated with diet and a statin. The K/DOQI guidelines also make it clear that the evidence supporting treatment in CKD populations is lacking however, and that additional placebo-controlled trials are needed. In the mean time, the high incidence of CVD makes intensive monitoring and treatment of dyslipidemias in patients with CKD a reasonable clinical approach.

Adult↗
PubMed2005

Long-term deterioration of kidney allograft function.

Although long-term survival after kidney transplantation is critically dependent on maintaining stable allograft function, few studies have examined renal allograft function over time. Using pooled data from 10 278 consecutive transplants at five centers, we calculated slopes of estimated glomerular filtration rates (eGFR) measured after 1, 6 and 12 months in 9515, 8861 and 7359 patients surviving > or =1, > or =6 and > or =12 months, respectively. Slopes of eGFR progressively diminished for patients transplanted during 1984-1989, 1990-1993, 1994-1998 and 1999-2002 (analysis of variance p < 0.0001 and p = 0.1245 for slopes measured after 1 and 6 months, respectively). Slopes measured after 12 months were less in the most recent era: -2.2 +/- 7.2 mL/min/1.73 m(2)/year, -2.3 +/- 6.6 mL/min/1.73 m(2)/year, -2.4 +/- 7.4 mL/min/1.73 m(2)/year and -1.4 +/- 10.9 mL/min/1.73 m(2)/year, respectively, p = 0.0058. Slopes measured after 1, 6 and 12 months each were less for transplantations during 1999-2002, after adjusting for multiple transplantation characteristics (p < 0.0001). Similarly, in Cox proportional hazards analysis, the risk (95% CI) for a 25% reduction in eGFR was 0.92 (0.85-1.01), p = 0.0736 during 1990-1994; 0.94 (0.82-1.08), p = 0.4111 during 1995-1998 and 0.78 (0.64-0.95), p = 0.0110 during 1999-2002 (compared to 1984-1989). We conclude that the rate of decline in allograft function after kidney transplantation has improved, suggesting that stable, long-term function may be achievable.

Adolescent↗
PubMed2005

Iso-osmolar radio contrast iodixanol in patients with chronic kidney disease.

BACKGROUND: Although radio contrast volume has been associated with worsening post-procedural kidney function, this relationship has not been extensively studied using an iso-osmolar contrast agent in chronic kidney disease patients. METHODS: We retrospectively studied patients undergoing cardiac catheterization at the University of Minnesota from 2000 to 2004, using the iso-osmolar contrast agent, iodixanol. All patients were included who had calculated creatinine clearance (CCR) < 60 mL/min, not on dialysis, and serum creatinine measured on the same day and within 7 days after the procedure. Comparison of a subgroup with severe chronic kidney disease and diabetes mellitus was compared to a similar historical control group that used the low-osmolar contrast agent, iohexol. RESULTS: Serum creatinine and CCR were 2.9 +/- 1.5 mg/dL and 33.4 +/- 12.0 mL/min (mean +/- standard deviation), respectively, at baseline in 117 cases. Peak creatinine increased by 0.03 +/- 0.7 mg/dL after 84.3 +/- 67.3 mL of iodixanol was used. Contrast-induced nephropathy definition was fulfilled in 22 (18.8%) cases. A non-significant negative correlation was found between the volume of iodixanol and the change in creatinine (r2 = 0.0011, p = 0.7254). A subgroup with severe chronic kidney disease and diabetes mellitus with iodixanol had a significantly lower creatinine increase (n = 25, 0.09 +/- 0.5 mg/dL), compared to historical controls (n = 42, 0.7 +/- 0.8 mg/dL) with iohexol (p < 0.001). A non-significant positive correlation between volume of contrast and change in creatinine was found in this subgroup who received iodixanol (n = 25, r2 = 0.0756, p = 0.1835), but was significant in the historical controls who received iohexol (n = 42, r2 = 0.135, p = 0.017). CONCLUSIONS: The volume of iso-osmolar radio contrast does not affect the incidence of contrast-induced nephropathy in patients with chronic kidney disease. A randomized trial evaluating the incidence of contrast nephropathy would verify the safety of ad hoc versus staged angiographic procedures in this population.

Adult↗
PubMed2004

Hypertension after kidney transplantation.

BACKGROUND: Few studies have examined the possible role of blood pressure (BP), independent of acute rejection and graft function, on outcomes after kidney transplantation. METHODS: We investigated the prevalence, treatment, control, and clinical correlates of hypertension and its association with outcomes, using multivariate analyses with time-dependent covariates, in a retrospective cohort of 1,666 kidney transplant recipients. RESULTS: Hypertension was common, and its control was poor. For example, at 1 year, only 55.5% had a BP less than 140 mm Hg. Control improved only slightly in 1993-2002 compared to 1976-2002, even as patients administered 2 or more antihypertensive medications at 1 year increased from 43.5% to 54.6%. Independent correlates of higher BP included male sex, age, donor age, diabetes, body mass index, the presence of native kidneys, and delayed graft function. Previous acute rejection was associated with higher BP at virtually all times after transplantation, and these associations were independent of estimated creatinine clearance (C(Cr)). Conversely, an association between BP and subsequent acute rejection was not statistically significant when differences in C(Cr) were taken into account. After adjusting for the effects of acute rejection, C(Cr), and other variables, each 10 mm Hg of systolic BP was associated with an increased relative risk for graft failure (1.12; 95% confidence interval, 1.08 to 1.15; P < 0.0001), death-censored graft failure (1.17; 1.12 to 1.22; P < 0.0001), and death (1.18; 1.12 to 1.23; P < 0.0001). CONCLUSION: High BP is closely tied to graft function, but nevertheless is an independent risk factor for graft failure and mortality. Better strategies are needed to control BP after kidney transplantation.

Adult↗
PubMed2004

Cancer after kidney transplantation in the United States.

Previous reports of cancer after kidney transplantation have been limited by small numbers of patients in single-center studies and incomplete ascertainment of cases in large registries. We examined rates of malignancies among first-time recipients of deceased or living donor kidney transplantations in 1995-2001 (n = 35 765) using Medicare billing claims. For most common tumors, e.g. colon, lung, prostate, stomach, esophagus, pancreas, ovary and breast, cancer rates were roughly twofold higher after kidney transplantation compared with the general population. Melanoma, leukemia, hepatobiliary tumors, cervical and vulvovaginal tumors were each approximately fivefold more common. Testicular and bladder cancers were increased approximately threefold, while kidney cancer was approximately 15-fold more common. Kaposi's sarcoma, non-Hodgkin's lymphomas, and nonmelanoma skin cancers were more than 20-fold increased than in the general population. Compared with patients on the waiting list, several tumors were more common after transplantation (p < 0.01): nonmelanoma skin cancers (2.6-fold), melanoma (2.2-fold), Kaposi's sarcoma (9.0-fold), non-Hodgkin's lymphoma (3.3-fold), cancer of the mouth (2.2-fold), and cancer of the kidney (39% higher). The rates for most malignancies are higher after kidney transplantation compared with the general population. Cancer should continue to be a major focus of prevention in kidney transplantation.

Adolescent↗
PubMed2004

Transplantation in the diabetic patient with advanced chronic kidney disease: a task force report.

On May 7 to 8, 2003, more than 60 physicians, surgeons, nurses, and allied health professionals met in Chicago, IL, to discuss state-of-the-art approaches to transplantation in the clinical management of patients with diabetes and advanced chronic kidney disease. Four work groups addressed pretransplantation evaluation and management, therapeutic alternatives for treatment of patients with chronic kidney disease, posttransplantation diabetes mellitus, and improving long-term kidney transplant outcomes in patients with diabetes. This report summarizes the deliberations and recommendations of the task force.

Coronary Disease↗
PubMed2003

Diabetes mellitus after kidney transplantation in the United States.

New onset diabetes is a major complication after kidney transplantation. However, the incidence, risk factors and clinical relevance of post-transplant diabetes mellitus (PTDM) vary among reports from single-center observational studies and clinical trials. Using data from the United Renal Data System we identified 11 659 Medicare beneficiaries who received their first kidney transplant in 1996-2000. The cumulative incidence of PTDM was 9.1% (95% confidence interval = 8.6-9.7%), 16.0% (15.3-16.7%), and 24.0% (23.1-24.9%) at 3, 12, and 36 months post-transplant, respectively. Using Cox's proportional hazards analysis, risk factors for PTDM included age, African American race (relative risk = 1.68, range: 1.52-1.85, p < 0.0001), Hispanic ethnicity (1.35, range: 1.19-1.54, p < 0.0001), male donor (1.12, range: 1.03-1.21, p = 0.0090), increasing HLA mismatches, hepatitis C infection (1.33, range: 1.15-1.55, p < 0.0001), body mass index >or=30 kg/m2 (1.73, range: 1.57-1.90, p < 0.0001), and the use of tacrolimus as the initial maintenance immunosuppressive medication (1.53, range: 1.29-1.81, p < 0.0001). Factors that reduced the risk for PTDM included the use of mycophenolate mofetil, azathioprine, younger recipient age, glomerulonephritis as a cause of kidney failure, and a college education. As a time-dependent covariate in Cox analyses that also included multiple other risk factors, PTDM was associated with increased graft failure (1.63, 1.46-1.84, p < 0.0001), death-censored graft failure (1.46, 1.25-1.70, p < 0.0001), and mortality (1.87, 1.60-2.18, p < 0.0001). We conclude that high incidences of PTDM are associated with the type of initial maintenance immunosuppression, race, ethnicity, obesity and hepatitis C infection. It is a strong, independent predictor of graft failure and mortality. Efforts should be made to minimize the risk of this important complication.

Adolescent↗