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Clinical Epidemiology
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Incidence, Risk Factors, and Sequelae of Post-kidney Transplant Delirium

Christine E. Haugen, Alexandra Mountford, Fatima Warsame, Rachel Berkowitz, Sunjae Bae, Alvin G. Thomas, Charles H. Brown, Daniel C. Brennan, Karin J. Neufeld, Michelle C. Carlson, Dorry L. Segev and Mara McAdams-DeMarco
JASN June 2018, 29 (6) 1752-1759; DOI: https://doi.org/10.1681/ASN.2018010064
Christine E. Haugen
1Departments of Surgery,
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Alexandra Mountford
1Departments of Surgery,
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Fatima Warsame
1Departments of Surgery,
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Rachel Berkowitz
1Departments of Surgery,
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Sunjae Bae
1Departments of Surgery,
2Departments of Epidemiology and
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Alvin G. Thomas
1Departments of Surgery,
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Charles H. Brown IV
3Anesthesiology and Critical Care Medicine,
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Daniel C. Brennan
4Medicine, and
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Karin J. Neufeld
5Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland;
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Michelle C. Carlson
6Mental Health, Johns Hopkins School of Public Health, Baltimore, Maryland; and
7Johns Hopkins University Center on Aging and Health, Baltimore, Maryland
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Dorry L. Segev
1Departments of Surgery,
2Departments of Epidemiology and
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Mara McAdams-DeMarco
1Departments of Surgery,
2Departments of Epidemiology and
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    Figure 1.

    The incidence of post-kidney transplant (KT) delirium increased by recipient age and frailty status.

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    Figure 2.

    The time to discharge after kidney transplantation was longer for recipients with post-KT delirium. The median time to discharge differed between KT recipients with and without delirium (16 versus 8 days; P<0.001).

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    Figure 3.

    The cumulative incidence of mortality was greater among recipients with post-kidney transplant (KT) delirium. The log rank P value was <0.001.

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    Table 1.

    Characteristics of 893 kidney transplant recipients by post-kidney transplant delirium

    CharacteristicNo DeliriumDelirium
    N (%)851 (95.3)42 (4.7)
    Recipient characteristics
     Women38.940.5
     Black40.457.1
     Age, yr52.2 (14.1)60.4 (14.4)
     Years on dialysis2.9 (3.6)3.6 (6.1)
     BMI28.4 (6.9)28.3 (4.9)
     High school education or less40.442.9
     Time on dialysis, yr2.9 (3.6)3.6 (6.1)
     Cause of ESRD
      Diabetes16.233.3
      Hypertension31.545.2
      Glomerular disease26.69.5
      Cystic disease10.60
      Other15.111.9
     Frail15.631.0
     Cognitive impairment9.119.1
     Global cognitive function92.1 (10.3)88.2 (10.2)
     Poor HRQOL8.811.9
     Depressive symptoms11.316.7
     ADL disability4.923.8
     IADL disability13.838.1
    Comorbidities
     Charlson Comorbidity Index1.5 (1.7)2.6 (2.2)
     Myocardial infarction5.214.3
     Peripheral vascular disease5.911.9
     Cerebral vascular disease2.10
     Dementia00
     Chronic lung conditions7.311.9
     Rheumatologic disorders20.628.6
     Peptic ulcers3.67.1
     Diabetes30.250.0
     Moderate/severe liver disease2.04.8
     Metastatic cancer00
     Leukemia0.20
     Lymphoma0.10
     HIV2.00
    Transplant characteristics
     Deceased donor61.281.0
     Not on standard triple therapy8.717.1
     DGF22.940.5
     PRA>80%14.74.8
     Cold ischemia time, ha26 (19–33)24 (18–34)
    • Characteristics are presented as percentages for binary variables and means (SD) for continuous variables except cold ischemia time, in which the medians (interquartile ranges) are presented. BMI, body mass index; HRQOL, health-related quality of life; ADL, activities of daily living; IADL, instrumental activities of daily living; DGF, delayed graft function; PRA, panel reactive antibody.

    • ↵a For deceased donor recipients.

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    Table 2.

    Risk prediction models for post-kidney transplant delirium among kidney transplant recipients

    Risk FactorOdds Ratio (95% CI)P Value
    Age 65 yr or older2.65 (1.36 to 5.18)0.004
    Frail2.05 (1.02 to 4.13)0.04
    Deceased donor KT2.03 (0.91 to 4.52)0.10
    Two or more on the Charlson Comorbidity Index1.93 (1.01 to 3.71)0.05
    Years on dialysis1.06 (0.99 to 1.15)0.10
    • All hazard ratios are from a single adjusted Cox proportional hazards model for delirium. The area under the receiver operating characteristic curve for the model is 0.73. 95% CI, 95% confidence interval; KT, kidney transplant.

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    Table 3.

    The association between post-kidney transplant (KT) delirium and length of stay, discharge location, death-censored graft loss, and mortality

    SequelaeUnadjusted (95% CI)Adjusted (95% CI)
    Length of stay
     Days, RR2.67 (2.27 to 3.14)2.49 (2.13 to 2.91)
     2 wk or Longer length of stay, OR5.89 (3.09 to 11.21)5.42 (2.76 to 10.66)
    Institutional discharge, OR30.11 (11.42 to 79.36)22.41 (7.85 to 63.98)
    Death-censored graft loss, HR2.81 (1.21 to 6.54)2.73 (1.14 to 6.53)
    Mortality, HR4.72 (2.71 to 8.20)3.12 (1.76 to 5.54)
    • All models are adjusted for the recipient, transplant, and donor factors listed in Table 2. 95% CI, 95% confidence interval; RR, ratio of time; OR, odds ratio; HR, hazard ratio.

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    Table 4.

    Risk of death-censored graft loss and mortality for kidney transplant recipients with and without post-kidney transplant delirium

    SequelaeRisk, %
    1 yr3 yr5 yr
    Death-censored graft loss
     No delirium2.35.59.2
     Delirium13.016.116.1
    Mortality
     No delirium2.27.310.4
     Delirium19.333.440.9
    • The risks (cumulative incidences) are expressed as percentages, and they are estimated using a Kaplan–Meier approach.

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Journal of the American Society of Nephrology: 29 (6)
Journal of the American Society of Nephrology
Vol. 29, Issue 6
June 2018
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Incidence, Risk Factors, and Sequelae of Post-kidney Transplant Delirium
Christine E. Haugen, Alexandra Mountford, Fatima Warsame, Rachel Berkowitz, Sunjae Bae, Alvin G. Thomas, Charles H. Brown, Daniel C. Brennan, Karin J. Neufeld, Michelle C. Carlson, Dorry L. Segev, Mara McAdams-DeMarco
JASN Jun 2018, 29 (6) 1752-1759; DOI: 10.1681/ASN.2018010064

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Incidence, Risk Factors, and Sequelae of Post-kidney Transplant Delirium
Christine E. Haugen, Alexandra Mountford, Fatima Warsame, Rachel Berkowitz, Sunjae Bae, Alvin G. Thomas, Charles H. Brown, Daniel C. Brennan, Karin J. Neufeld, Michelle C. Carlson, Dorry L. Segev, Mara McAdams-DeMarco
JASN Jun 2018, 29 (6) 1752-1759; DOI: 10.1681/ASN.2018010064
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