Obese patients have a decreased risk of death on dialysis but an increased risk of death after transplantation, and may derive a lower survival benefit from transplantation. Using data from the United States between 1995 and 2007 and multivariate non-proportional hazards analyses we determined the relative risk of death in transplant recipients grouped by body mass index (BMI) compared to wait-listed candidates with the same BMI (n ¼ 208 498). One year after transplantation the survival benefit of transplantation varied by BMI: Standard criteria donor transplantation was associated with a 48% reduction in the risk of death in patients with BMI ! 40 kg/m 2 but a !66% reduction in patients with BMI < 40 kg/m 2 . Living donor transplantation was associated with !66% reduction in the risk of death in all BMI groups. In sub-group analyses, transplantation from any donor source was associated with a survival benefit in obese patients !50 years, and diabetic patients, but a survival benefit was not demonstrated in Black patients with BMI ! 40 kg/m 2 . Although most obese patients selected for transplantation derive a survival benefit, the benefit is lower when BMI is !40 kg/m 2 , and uncertain in Black patients with BMI ! 40 kg/m 2 .

Objective To determine the cost effectiveness of one-off population based screening for chronic kidney disease based on estimated glomerular filtration rate.Design Cost utility analysis of screening with estimated glomerular filtration rate alone compared with no screening (with allowance for incidental finding of cases of chronic kidney disease). Analyses were stratified by age, diabetes, and the presence or absence of proteinuria. Scenario and sensitivity analyses, including probabilistic sensitivity analysis, were performed. Costs were estimated in all adults and in subgroups defined by age, diabetes, and hypertension.Setting Publicly funded Canadian healthcare system.Participants Large population based laboratory cohort used to estimate mortality rates and incidence of end stage renal disease for patients with chronic kidney disease over a five year follow-up period. Patients had not previously undergone assessment of glomerular filtration rate. Main outcome measures Lifetime costs, end stage renal disease, quality adjusted life years (QALYs) gained, and incremental cost per QALY gained.Results Compared with no screening, population based screening for chronic kidney disease was associated with an incremental cost of $C463 (Canadian dollars in 2009; equivalent to about £275, €308, US $382) and a gain of 0.0044 QALYs per patient overall, representing a cost per QALY gained of $C104 900. In a cohort of 100 000 people, screening for chronic kidney disease would be expected to reduce the number of people who develop end stage renal disease over their lifetime from 675 to 657. In subgroups of people with and without diabetes, the cost per QALY gained was $C22 600 and $C572 000, respectively. In a cohort of 100 000 people with diabetes, screening would be expected to reduce the number of people who develop end stage renal disease over their lifetime from 1796 to 1741. In people without diabetes with and without hypertension, the cost per QALY gained was $C334 000 and $C1 411 100, respectively.Conclusions Population based screening for chronic kidney disease with assessment of estimated glomerular filtration rate is not cost effective overall or in subgroups of people with hypertension or older people. Targeted screening of people with diabetes is associated with a cost per QALY that is similar to that accepted in other interventions funded by public healthcare systems.

Background and objectives Obese patients encounter barriers to medical care not encountered by lean patients, and inequities in access to care among obese patients may vary by sex. This study aimed to determine the association of body mass index (BMI) with access to kidney transplantation in men and women.Design, setting, participants, & measurements In this retrospective analysis of 702,456 incident ESRD patients aged 18-70 years (captured in the US Renal Data System between 1995 and 2007), multivariate time-to-event analyses were used to determine the association of BMI with likelihood of transplantation from any donor source, transplantation from a living donor, and transplantation from a deceased donor, as well the individual steps in obtaining a deceased donor transplant (activation to the waiting list, and transplantation after wait-listing).Results Among women, a BMI$25.0 kg/m 2 was associated with a lower likelihood of transplantation from any donor source (hazard ratio [HR], 0.75; 95% confidence interval [95% CI], 0.73 to 0.77), transplantation from a living donor (HR, 0.75; 95% CI, 0.72 to 0.77), and transplantation from a deceased donor (HR, 0.74; 95% CI, 0.72 to 0.77). By contrast, among men, a BMI of 25.0-34.9 kg/m 2 was associated with a higher likelihood of the outcomes of transplantation from any donor source (HR, 1.08; 95% CI, 1.06 to 1.11), transplantation from a living donor (HR, 1.18; 95% CI, 1.13 to 1.22), and transplantation from a deceased donor (HR, 1.05; 95% CI, 1.02 to 1.07). Among men, the level beyond which BMI was associated with a lower likelihood of transplantation from any donor source or a living donor was $40.0 kg/m 2 , and $35.0 kg/m 2 in the case of deceased donor transplantation. ConclusionsThe association of BMI with access to transplantation varies between men and women. The reasons for this difference should be further studied.Clin J Am Soc Nephrol 9: 951-959, 2014.

Concern about the long-term impact of delayed graft function (DGF) may limit the use of high-risk organs for kidney transplantation. To understand this better, we analyzed 29,598 mate kidney transplants from the same deceased donor where only 1 transplant developed DGF. The DGF associated risk of graft failure was greatest in the first posttransplant year, and in patients with concomitant acute rejection (hazard ratio: 8.22, 95% confidence interval: 4.76-14.21). In contrast, the DGF-associated risk of graft failure after the first posttransplant year in patients without acute rejection was far lower (hazard ratio: 1.15, 95% confidence interval: 1.02-1.29). In subsequent analysis, recipients of transplants complicated by DGF still derived a survival benefit when compared with patients who received treatment with dialysis irrespective of donor quality as measured by the Kidney Donor Profile Index (KDPI). The difference in the time required to derive a survival benefit was longer in transplants with DGF than in transplants without DGF, and this difference was greatest in recipients of lower quality kidneys (difference: 250-279 days for KDPI 20%-60% vs. 809 days for the KDPI over 80%). Thus, the association of DGF with graft failure is primarily limited to the first posttransplant year. Transplants complicated by DGF provide a survival benefit compared to treatment with dialysis, but the survival benefit is lower in kidney transplants with lower KDPI. This information may increase acceptance of kidneys at high risk for DGF and inform strategies to minimize the risk of death in the setting of DGF.

PP is associated with a reduced risk of DGF irrespective of donor type and CIT. Although PP modifies the impact of CIT on the risk of DGF, it does not eliminate its association with DGF, suggesting the optimal strategy to reduce DGF is to minimize CIT and utilize PP in all deceased donor transplants.