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Background: Post-transplant diabetes mellitus (PTDM) is an important complication after kidney transplantation that results in reduced patient and allograft survival. Although there are established risk factors for PTDM, whether pretransplant C-peptide levels associate with PTDM is unknown. Therefore, in this study, we aimed to examine the association of pretransplant C-peptide levels with PTDM., Methods: This was a cohort study of nondiabetic adult patients who underwent kidney transplant in Nova Scotia, Canada, between January 1, 2016, and March 31, 2021, with fasting C-peptide levels measured before transplant. Multivariable logistic regression was used to determine the association of pretransplant C-peptide (dichotomized around the median) with PTDM at 1 year post transplant. Given the known association between pretransplant obesity and PTDM, we repeated our primary analysis in a cohort restricted to a BMI of 20-35 kg/m 2 ., Results: The median C-peptide value was 3251 (Q1 2480, Q3 4724); pretransplant C-peptide level was dichotomized at 3000 pmol/L. PTDM occurred in 25 (19%) individuals. Thirty percent of patients in the high and only 2% of patients in the low C-peptide groups developed PTDM ( P <0.001). A C-peptide level ≥3000 pmol/L was strongly associated with PTDM in multivariable analysis (OR=18.9, 95% CI, 2.06 to 174.2). In a restricted cohort with a BMI of 20-35 kg/m 2 , an elevated pretransplant C-peptide remained independently associated with the risk of PTDM (OR=15.7, 95% CI, 1.64 to 150.3). C-peptide was the only factor independently associated with PTDM in this restricted BMI cohort., Conclusions: A pretransplant C-peptide level ≥3000 pmol/L was associated with a nearly 20-fold increased odds of PTDM at 1 year post kidney transplantation. Identifying patients with high pretransplant C-peptide levels may therefore help identify those at risk for PTDM who may benefit from focused preventative and therapeutic interventions and support., Competing Interests: L. Gunaratnam reports consultancy for AstraZeneca Canada, Inc., Novartis Canada Inc., and Paladin Labs, Inc.; honoraria from AstraZeneca Canada, Inc., Novartis Canada Inc., and Paladin Labs Inc.; an advisory or leadership role for AstraZeneca Canada, Inc., Bayer, Inc., and Paladin Labs, Inc.; and participation in a speakers’ bureau for AstraZeneca Canada, Inc. K.K. Tennankore reports consultancy for AstraZeneca, Bayer, GSK, Otsuka, and Vifor; research funding from Otsuka Canada; honoraria from Astra Zeneca, Baxter, GSK, and Otsuka; an advisory or leadership role for the Canadian Journal of Kidney Health and Disease (associate editor); and participating in a speakers’ bureau for AstraZeneca, Baxter, and Bayer. A.J. Vinson reports consultancy for Paladin Labs, Inc., and research funding from Paladin Labs, Inc. K. West reports consultancy for Envarsus Canada, and honoraria from Envarsus Canada. All remaining authors have nothing to disclose., (Copyright © 2022 by the American Society of Nephrology.)

Background: Hyperkalemia is common among patients on maintenance hemodialysis (HD) and is associated with mortality. We hypothesized that clinical characteristics available at time of paramedic assessment before emergency department (ED) ambulance transport (ambulance-ED) would associate with severe hyperkalemia (K≥6 mmol/L). Rapid identification of patients who are at risk for hyperkalemia and thereby hyperkalemia-associated complications may allow paramedics to intervene in a timely fashion, including directing emergency transport to dialysis-capable facilities., Methods: Patients on maintenance HD from a single paramedic provider region, who had at least one ambulance-ED and subsequent ED potassium from 2014 to 2018, were examined using multivariable logistic regression to create risk prediction models inclusive of prehospital vital signs, days from last dialysis, and the presence of prehospital electrocardiogram (ECG) features of hyperkalemia. We used bootstrapping with replacement to validate each model internally, and performance was assessed by discrimination and calibration., Results: Among 704 ambulance-ED visits, severe hyperkalemia occurred in 75 (11%); 26 patients with ED hyperkalemia did not have a prehospital ECG. Younger age at transport, longer HD vintage, more days from last hemodialysis session (OR=49.84; 95% CI, 7.72 to 321.77 for ≥3 days versus HD the same day [before] ED transport), and prehospital ECG changes (OR=6.64; 95% CI, 2.31 to 19.12) were independently associated with severe ED hyperkalemia. A model incorporating these factors had good discrimination (c-statistic 0.82; 95% CI, 0.76 to 0.89) and, using a cutoff of 25% probability, correctly classified patients 89% of the time., Conclusions: Characteristics available at the time of ambulance-ED were associated with severe ED hyperkalemia. An awareness of these associations may allow health care providers to define novel care pathways to ensure timely diagnosis and management of hyperkalemia., Competing Interests: D.A. Clark reports research funding from Otsuka Canada Pharmaceutical, Inc., and honoraria from Baxter Canada. P.T. Fok reports ownership interest in Merck Pharmaceuticals and Moderna, Inc., but is no longer holding stocks of either company, and is on the Board of Directors of the Canadian Association of Emergency Physicians but receives no compensation for this. K.K. Tennankore reports consultancy for AstraZeneca, Baxter, Bayer, and Otsuka; research funding from Otsuka Canada; honoraria from Astra Zeneca, Baxter, Bayer, and Otsuka; being associate editor for the Canadian Journal of Kidney Health and Disease; and participating in a speakers’ bureau for AstraZeneca, Baxter, and Bayer. A.J. Vinson reports consultancy for Paladin Labs, Inc., and research funding from Paladin Labs, Inc. H. Wiemer reports research funding from Purdue Pharma (Canada). All remaining authors have nothing to disclose., (Copyright © 2022 by the American Society of Nephrology.)

Background: The need for repeat transplant due to failing kidney allografts is increasing over time. The benefit of preemptive kidney retransplant (PKre-T) is controversial. Marginalized populations are less likely to undergo their first transplant preemptively; however, whether inequities exist for those undergoing PKre-T is unknown., Methods: We performed a cohort study of adult patients undergoing live and deceased kidney transplant in the United States from 2000 to 2018 identified using the Scientific Registry of Transplant Recipients, and we identified patients with first preemptive kidney transplant (PKT) and PKre-T. In the primary analysis, a multivariable logistic regression was used to identify independent predictors of PKre-T. In secondary analyses, multivariable Cox models were used to determine the association of PKre-T with death-censored and all-cause graft loss., Results: In total, 4910 (15.5%) patients underwent PKre-T, and 43,293 (19.1%) underwent first PKT. Inequities in access to PKre-T persisted (OR, 0.49; 95% CI, 0.44 to 0.55 for unemployed versus full time; OR, 1.61; 95% CI, 1.14 to 2.25 for graduate school versus not completing high school; OR, 0.61; 95% CI, 0.52 to 0.70 for Black versus White race); 7.1% of all transplanted Black patients received PKre-T versus 17.4% of White patients. Women were more likely to undergo PKre-T than men (OR, 1.42; 95% CI, 1.29 to 1.57). PKre-T was associated with superior graft survival relative to retransplant after a period of dialysis (HR, 0.73; 95% CI, 0.67 to 0.80 for all-cause graft failure; HR, 0.72; 95% CI, 0.65 to 0.81 for death-censored graft loss)., Conclusions: Despite improved patient and graft survival, inequities in access to PKre-T persist. Patients with lower education, patients with reduced employment status, patients of Black race, and men are less likely to receive PKre-T., Competing Interests: B.J. Foster reports research funding as a coinvestigator from two grants sponsored by Astellas Canada. R.B. Mannon reports research funding from Astellas, CareDx, CSL Behring, Mallinckrodt, Quark Pharmaceuticals, and Transplant Genomics, Inc.; honoraria from CSL Behring, Hansa, Novartis, Sanofi, and Vitaerris; scientific advisor or membership with the steering committee of the Vitaeris VKTX01 Clazakizumab for the Treatment of Chronic Active Antibody Mediated Rejection in Kidney Transplant Recipients (IMAGINE) Trial; and other interests/relationships as the chair of Data Safety Monitoring Board for the National Institute of Diabetes and Digestive and Kidney Diseases/National Institutes of Health, member of the American Society of Nephrology (ASN) Grants Committee, chair of the ASN Policy and Advocacy Committee, chair of Women in Transplantation, member of the Program Committee TTS 2020 and 2022, and cochair of the SRTR Review Committee. K.K. Tennankore reports consultancy agreements with AstraZeneca, Baxter, Bayer, Janssen, and Otsuka; research funding from Astellas Canada and Otsuka Canada; honoraria from Astra Zeneca, Bayer, and Otsuka; scientific advisor or membership as an associate editor of the Canadian Journal of Kidney Health and Disease; and speakers bureau for AstraZeneca, Baxter, and Bayer. A.J. Vinson reports consultancy agreements with Paladin Labs Inc. and research funding from Paladin Labs Inc. K. West reports consultancy agreements with Envarsus Canada and honoraria from Envarsus Canada. The remaining author has nothing to disclose., (Copyright © 2022 by the American Society of Nephrology.)