|
1
|
Arain SJ, Morrell AH. Liquefaction of renal allograft: An unprecedented complication in transplantation medicine. ULTRASOUND (LEEDS, ENGLAND) 2025:1742271X251337256. [PMID: 40352599 PMCID: PMC12058698 DOI: 10.1177/1742271x251337256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2024] [Accepted: 03/06/2025] [Indexed: 05/14/2025]
Abstract
Background Renal transplantation stands as the gold standard treatment for end-stage renal disease, offering improved quality of life and increased survival compared to dialysis. However, despite its advantages, renal allograft failure can occur, necessitating careful management to mitigate associated complications. Instances of liquefaction of the transplanted kidney are exceedingly rare, posing unique challenges to clinicians in the management of allograft failure. Existing literature highlights the complexities surrounding decisions regarding dialysis reinitiation, immunosuppression management, and the potential need for transplant nephrectomy in patients with failed renal allografts. Case presentation A 52-year-old Caucasian female with a complex medical history including stage 5 chronic kidney disease, non-ST-segment elevation myocardial infarction, hypertrophic cardiomyopathy with mild left ventricular systolic dysfunction, atrial fibrillation, and a history of cardiac arrest resulting in hypoxic brain injury, presented with a unique complication following renal transplantation. Imaging studies revealed complete breakdown and liquefaction of the transplanted kidney in the right iliac fossa. Despite interventions such as ultrasound-guided aspiration and drainage, the patient's condition continued to deteriorate. Conclusion This case highlights a rare occurrence of allograft liquefaction following renal transplantation, emphasising the need for vigilance in monitoring transplant recipients for uncommon complications. The management of such cases requires a multidisciplinary approach, considering factors such as dialysis reinitiation timing, immunosuppression management, and the potential need for transplant nephrectomy. Further research is warranted to elucidate the pathophysiology and optimal management strategies for unique complications such as allograft liquefaction, underscoring the importance of individualised treatment approaches in complex clinical scenarios.
Collapse
Affiliation(s)
| | - Adam H Morrell
- Faculty of Medicine and Health, University of Leeds, Leeds, UK
| |
Collapse
|
|
2
|
Chen YA, Lai TS, Tsao HM, Chen YT. Comparison of outcomes between kidney transplant-naïve and post-transplant graft failure peritoneal dialysis patients. J Formos Med Assoc 2025:S0929-6646(25)00210-4. [PMID: 40328595 DOI: 10.1016/j.jfma.2025.04.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2025] [Revised: 04/23/2025] [Accepted: 04/30/2025] [Indexed: 05/08/2025] Open
Abstract
BACKGROUND This study was conducted to compare clinical outcomes between transplant-naïve peritoneal dialysis (PD) patients and those returning to PD after a failed allograft. METHODS In this retrospective cohort study during 2006 and 2016, we included a total of 786 patients on chronic PD. Of them 679 were transplant-naïve, 75 patients underwent a successful transplantation, and 32 patients returned to PD after a failed kidney allograft. Baseline demographics and clinical characteristics were analyzed in relation to the outcomes of all-cause mortality and peritonitis rate. We employed the Kaplan-Meier method and Cox proportional hazards model to evaluate survival, while Poisson regression was utilized to estimate rate ratios for peritonitis. RESULTS During a median follow-up of 6.37 years, 56.68 % death and 146.62 episodes of peritonitis/patient-year were observed. Compared with patients who received a kidney graft, transplant-naïve patients were older, more with diabetes and having higher mortality (58.6 ± 15.8, 40.5 % and 57.73 %, p < 0.0001). After accounting for age, gender, and comorbidities, the adjusted hazards ratios were 0.26 (95 % CI 0.13-0.53) in patients with a functioning graft and 1.12 (95 % CI 0.61-2.06) in patients returning to PD after graft failure, compared respectively with concurrent PD patients without kidney transplant. The adjusted rate ratio of peritonitis in patients resuming PD after graft failure was 0.55 (95 % CI: 0.22-1.14) compared to those without kidney transplant. CONCLUSIONS Patients restarting PD after graft failure exhibited clinical outcomes comparable to transplant-naïve PD patients. These findings support the feasibility of reinitiating PD after kidney transplant fails.
Collapse
Affiliation(s)
- Yung-An Chen
- Department of Medicine, National Taiwan University Hospital Jinshan Branch, New Taipei City, Taiwan
| | - Tai-Shuan Lai
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Hsiao-Mei Tsao
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yi-Ting Chen
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Division of Blood Purification, Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan.
| |
Collapse
|
|
3
|
Ploeger L, Elshoff PL, Kortus-Goetze B, Hoyer J, Russwurm M, Wild J. Utilization of Organs from Hepatitis C-Antibody-Positive or RNA-Positive Donors in Kidney Transplantation: A Single-Center Retrospective Analysis of Outcomes and Safety. J Clin Med 2025; 14:2653. [PMID: 40283483 PMCID: PMC12028162 DOI: 10.3390/jcm14082653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2025] [Revised: 04/03/2025] [Accepted: 04/09/2025] [Indexed: 04/29/2025] Open
Abstract
Background/Objectives: The shortage of donor organs in transplant medicine remains a challenge. Kidney transplantation from Hepatitis C (HCV)-positive donors to HCV-negative recipients expands the donor pool. Limited data suggest this approach as safe when combined with modern antiviral therapies. This study evaluates the safety of such transplantations in terms of viral transmission and graft function. Methods: A retrospective analysis of 205 kidney transplantations at the University Medical Center Marburg (January 2017-January 2024) was conducted. Eight recipients received kidneys from HCV-antibody-positive (HCV-Antibody+) and RNA-negative donors (HCV-RNA-), and five received kidneys from HCV-RNA-positive (HCV-RNA+) donors. Recipient demographics, donor factors, and transplantation parameters were analyzed. Repeated virological surveillance as well as graft function and complications were assessed within the first year after transplantation. Results: HCV-RNA+ donor recipients received Glecaprevir/Pibrentasvir for three months starting immediately at transplantation, while HCV-Antibody+ and HCV-RNA- donor recipients did not receive antiviral therapy. After 12 months, both groups exhibited comparable graft function (serum creatinine: HCV-Antibody+/RNA- 1.3 ± 0.4 mg/dL vs. HCV-RNA+ 1.8 ± 0.5 mg/dL, p = 0.6) without proteinuria. No hepatic complications or significant inflammation occurred. No HCV-RNA was detected in any patient at any time under the selected treatment regimen. Conclusions: This single-center study supports the safety of kidney transplantation from HCV-positive donors. Preemptive Glecaprevir/Pibrentasvir therapy effectively prevents HCV transmission, offering a viable option to expand the donor pool.
Collapse
Affiliation(s)
- Lara Ploeger
- Department of Internal Medicine and Nephrology, University Hospital Marburg, 35043 Marburg, Germany; (L.P.)
| | - Philipp Luetke Elshoff
- Department of Internal Medicine and Nephrology, University Hospital Marburg, 35043 Marburg, Germany; (L.P.)
| | - Birgit Kortus-Goetze
- Department of Internal Medicine and Nephrology, University Hospital Marburg, 35043 Marburg, Germany; (L.P.)
| | - Joachim Hoyer
- Department of Internal Medicine and Nephrology, University Hospital Marburg, 35043 Marburg, Germany; (L.P.)
| | - Martin Russwurm
- Department of Internal Medicine and Nephrology, University Hospital Marburg, 35043 Marburg, Germany; (L.P.)
- Pharmacological Institute, University Marburg, 35043 Marburg, Germany
| | - Johannes Wild
- Department of Internal Medicine and Nephrology, University Hospital Marburg, 35043 Marburg, Germany; (L.P.)
| |
Collapse
|
|
4
|
Masoumi-Ravandi K, Vinson A, Thanamayooran A, Goldstein J, Skinner T, Tennankore K. Ambulance Service Utilization by Kidney Transplant Recipients. Can J Kidney Health Dis 2025; 12:20543581251324587. [PMID: 40191783 PMCID: PMC11970094 DOI: 10.1177/20543581251324587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Accepted: 01/29/2025] [Indexed: 04/09/2025] Open
Abstract
Background Compared with the general population, kidney transplant recipients (KTRs) frequently visit the emergency department (ED), but much less is known about the characteristics of ED presentations requiring ambulance transport and the impact on subsequent outcomes for KTRs. Objectives To identify predictors of ambulance transport to the ED (ambulance-ED) and outcomes (graft failure and mortality) for those who experienced an ambulance-ED event in a cohort of KTRs. Design Retrospective cohort study of incident, adult KTRs receiving a transplant from 2008 to 2020. Setting Nova Scotia, Canada. Patients Adult (≥18 years), Nova Scotian KTRs affiliated with the Atlantic Canada Multi-Organ Transplant Program. Measurements Ambulance-ED events were captured for all transplant recipients (following the day of discharge from their initial transplant admission) using electronic records (provided by Emergency Health Services, the sole provider of emergency medical services for Nova Scotia). Ambulance-ED was defined as ambulance transport to the ED following a 911 call; interfacility transfers were excluded. Predictors of ambulance-ED included recipient, donor, immunological, and perioperative characteristics (pertaining to the initial admission for kidney transplantation). Outcomes included graft failure and mortality. Methods Predictors of ambulance-ED were analyzed using a multivariable negative binomial regression model and reported using incidence rate ratios (IRRs) and 95% confidence intervals (CIs). The risk of death/graft failure for those with an ambulance-ED within 30 days of hospital discharge following transplantation was analyzed using an adjusted Cox survival analysis and reported using hazard ratios (HRs) and 95% CIs. Results A total of 418 patients received a transplant during the study period. A total of 179 (42.8%) experienced one or more ambulance-ED events. Female sex (IRR = 1.60; 95% CI = 1.12-2.29), kidney failure secondary to diabetes (IRR = 2.52; 95% CI = 1.19-5.31), and donor age ≥45 (IRR = 1.50; 95% CI = 1.04-2.15) were all associated with ambulance-ED. There was no significant increase in the risk of death/graft failure for those that experienced ambulance-ED within 30 days of hospital discharge following transplantation (HR = 1.31; 95% CI = 0.44-3.94). Limitations A limitation of this study was that ambulance-ED is not a perfect surrogate marker of acute care needs in a population. Important determinants of health such as living situation and socioeconomic status were not available in this data set. Conclusions This study highlights the burden of ambulance use for KTRs and provides insight into the need for more optimal follow-up in certain patient subgroups who are at particularly high risk.
Collapse
Affiliation(s)
| | - Amanda Vinson
- Division of Nephrology, Dalhousie University, Halifax, NS, Canada
| | | | - Judah Goldstein
- Division of Emergency Medical Services, Dalhousie University, Halifax, NS, Canada
| | - Thomas Skinner
- Department of Urology, Dalhousie University, Halifax, NS, Canada
| | | |
Collapse
|
|
5
|
Khairallah P, Lorenz EC, Waterman A, Aggarwal N, Pai A, Winkelmayer WC, Niu J. Trends in Kidney Allograft Failure Among First-Time Transplant Recipients in the United States. Am J Kidney Dis 2025; 85:273-283.e1. [PMID: 39521400 DOI: 10.1053/j.ajkd.2024.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 08/28/2024] [Accepted: 09/17/2024] [Indexed: 11/16/2024]
Abstract
RATIONALE & OBJECTIVE The management and outcomes of kidney transplant recipients have evolved over the past 3 decades. This study of US patients whose first kidney allograft failed examined long-term trends in subsequent waitlisting, retransplantation, and all-cause mortality. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS Patients recorded in the US Renal Data System (USRDS) whose first kidney allograft failed between 1990 and 2019. EXPOSURE The 5-year period in which the allograft failure occurred: 1990-1994, 1995-1999, 2000-2004, 2005-2009, 2010-2014, or 2015-2019. OUTCOME (1) Waitlisting for retransplantation, (2) retransplantation, and (3) all-cause mortality following first allograft failure. ANALYTICAL APPROACH Competing risk survival analyses with the approach described by Fine and Gray used for the outcomes of waitlisting and retransplantation, and Cox proportional hazards models used for the outcome of all-cause mortality. RESULTS The absolute number of patients whose allograft failed and who started dialysis increased from 3,197 in 1990 to 5,821 in 2019. Compared with 1990-1994, the rate of waitlisting for a second transplant increased with each subsequent 5-year period, peaking between 2005 and 2009 before decreasing again subsequently. The rate of retransplantation following allograft failure decreased by 9%, 14%, 18%, 7%, and 11% in the sequential 5-year eras; and the mortality rate was 25% lower in 2015-2019 (HR, 0.75 [95% CI, 0.72-0.77]) compared with 1990-1994. Women had a reduced rate of waitlisting (HR, 0.93 [95% CI, 0.91-0.95]) and lower rate of retransplantation (HR, 0.93 [95% CI, 0.91-0.95]) compared with men. Compared with White patients, African American and Hispanic patients had significantly lower rates of waitlisting, retransplantation, and mortality. LIMITATIONS Retrospective data that lacks granular clinical information. CONCLUSIONS During the past 3 decades, among patients whose first kidney allograft failed and subsequently initiated dialysis, the rates of waitlisting for retransplantation increased while the rates of retransplantation and mortality decreased. Disparities based on race, ethnicity, and sex in waitlisting and retransplantation were observed and warrant further investigation. PLAIN-LANGUAGE SUMMARY Kidney allograft failure constitutes the fourth most common cause of dialysis initiation in the United States, and it accounts for 4% to 10% of yearly new dialysis starts globally. Little is known about the trends in the outcomes of patients whose kidney allograft failed. We studied US patients whose first kidney allograft failed between 1990 and 2019 to understand trends in waitlisting for retransplantation, retransplantation, and all-cause mortality after kidney allograft failure. Among patients whose first kidney allograft failed and started dialysis, rates of waitlisting increased and rates of retransplantation and mortality decreased over the past 3 decades. We found racial, ethnic, and sex-based disparities in outcomes. Compared with White patients, African American and Hispanic patients had significantly lower rates of waitlisting, retransplantation, and mortality. Women also had lower rates of waitlisting and retransplantation compared with men.
Collapse
Affiliation(s)
| | | | - Amy Waterman
- Department of Surgery and J.C. Walter Jr. Transplant Center, Houston Methodist Hospital, Houston, Texas
| | - Nidhi Aggarwal
- Section of Nephrology, Baylor College of Medicine, Houston, Texas
| | - Akshta Pai
- Section of Nephrology, Baylor College of Medicine, Houston, Texas
| | | | - Jingbo Niu
- Section of Nephrology, Baylor College of Medicine, Houston, Texas
| |
Collapse
|
|
6
|
Cheng L, Hu N, Song D, Liu L, Chen Y. Early versus late nephrology referral and patient outcomes in chronic kidney disease: an updated systematic review and meta-analysis. BMC Nephrol 2025; 26:25. [PMID: 39815172 PMCID: PMC11737272 DOI: 10.1186/s12882-025-03944-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2024] [Accepted: 01/03/2025] [Indexed: 01/18/2025] Open
Abstract
BACKGROUND Nephrology referral has been recognized as a modifiable factor influencing patient outcomes. The study aimed to compare clinical outcomes among patients referred early versus late to nephrologists. METHODS We searched online database from inception to June 1, 2022, to obtain all eligible literature reporting outcomes of patients referred early versus late to nephrologists. The early and late referral was defined by the time at which patients were referred to nephrologists before dialysis onset. RESULTS Seventy-two studies with over 630,000 patients met the inclusion criteria. A lower likelihood of all-cause mortality (HR = 0.67, 95% CI: 0.62-0.72) was achieved among patients referred early to nephrologists. The survival advantage of early referral was apparent in the first 6 months and extended to the 5th year after dialysis onset (6 months: HR = 0.52, 95% CI: 0.40-0.68; 5 years: HR = 0.67, 95% CI: 0.60-0.74). The early referral was associated with shorter durations of initial hospitalization, a higher rate of kidney transplantation (RR = 1.41, 95% CI: 1.12-1.78), a lower likelihood of emergency start (RR = 0.39, 95% CI: 0.28-0.54), a higher likelihood of permanent access creation (RR = 3.34, 95% CI: 2.43-4.59), increased initial use of permanent access (RR = 2.60, 95% CI: 2.18-3.11), and reduced initial catheter use (RR = 0.43, 95% CI: 0.32-0.58). CONCLUSIONS Our study showed a lower risk of mortality, shorter lengths of initial hospitalization, and better preparations for renal replacement therapy among patients referred early to nephrologists. Early nephrology care should be promoted to improve the management of advanced chronic kidney disease.
Collapse
Affiliation(s)
- Linan Cheng
- Renal Division, Peking University First Hospital, Beijing, 100034, China
- Institute of Nephrology, Peking University, Beijing, 100034, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, 100034, China
- Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Nan Hu
- Renal Division, Peking University First Hospital, Beijing, 100034, China
- Institute of Nephrology, Peking University, Beijing, 100034, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, 100034, China
- Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Di Song
- Renal Division, Peking University First Hospital, Beijing, 100034, China
- Institute of Nephrology, Peking University, Beijing, 100034, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, 100034, China
- Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Li Liu
- Renal Division, Peking University First Hospital, Beijing, 100034, China
- Institute of Nephrology, Peking University, Beijing, 100034, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, 100034, China
- Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Yuqing Chen
- Renal Division, Peking University First Hospital, Beijing, 100034, China.
- Institute of Nephrology, Peking University, Beijing, 100034, China.
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, 100034, China.
- Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China.
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China.
| |
Collapse
|
|
7
|
Slominska A, Loban K, Kinsella EA, Ho J, Sandal S. Supportive care in transplantation: A patient-centered care model to better support kidney transplant candidates and recipients. World J Transplant 2024; 14:97474. [PMID: 39697448 PMCID: PMC11438939 DOI: 10.5500/wjt.v14.i4.97474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Revised: 07/31/2024] [Accepted: 08/06/2024] [Indexed: 09/20/2024] Open
Abstract
Kidney transplantation (KT), although the best treatment option for eligible patients, entails maintaining and adhering to a life-long treatment regimen of medications, lifestyle changes, self-care, and appointments. Many patients experience uncertain outcome trajectories increasing their vulnerability and symptom burden and generating complex care needs. Even when transplants are successful, for some patients the adjustment to life post-transplant can be challenging and psychological difficulties, economic challenges and social isolation have been reported. About 50% of patients lose their transplant within 10 years and must return to dialysis or pursue another transplant or conservative care. This paper documents the complicated journey patients undertake before and after KT and outlines some initiatives aimed at improving patient-centered care in transplantation. A more cohesive approach to care that borrows its philosophical approach from the established field of supportive oncology may improve patient experiences and outcomes. We propose the "supportive care in transplantation" care model to operationalize a patient-centered approach in transplantation. This model can build on other ongoing initiatives of other scholars and researchers and can help advance patient-centered care through the entire care continuum of kidney transplant recipients and candidates. Multi-dimensionality, multi-disciplinarity and evidence-based approaches are proposed as other key tenets of this care model. We conclude by proposing the potential advantages of this approach to patients and healthcare systems.
Collapse
Affiliation(s)
- Anita Slominska
- MEDIC Program, Research Institute of the McGill University Health Centre, Montreal H4A3J1, QC, Canada
| | - Katya Loban
- MEDIC Program, Research Institute of the McGill University Health Centre, Montreal H4A3J1, QC, Canada
| | - Elizabeth Anne Kinsella
- Institute of Health Sciences Education, Faculty of Medicine and Health Sciences, McGill University, Montreal H4A3J1, QC, Canada
| | - Julie Ho
- Department of Medicine, University of Manitoba, Winnipeg R3A1R9, MB, Canada
| | - Shaifali Sandal
- Department of Medicine, McGill University Health Centre, Montreal H4A3J1, QC, Canada
| |
Collapse
|
|
8
|
Anand PM, Woodside KJ, Singh N, Alhamad T, Bloom RD, Gupta G, Singer G, Doshi M, Dadhania DM, Tanriover B, Parsons RF, Wagner C, Xiao H, Lentine KL. Transition of Care of Stable Kidney Transplant Patients to Referring Nephrologists: A Survey of U.S. Transplant Program Staff. Clin Transplant 2024; 38:e15484. [PMID: 39512123 DOI: 10.1111/ctr.15484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2024] [Revised: 09/26/2024] [Accepted: 09/29/2024] [Indexed: 11/15/2024]
Abstract
BACKGROUND AND OBJECTIVES We conducted a national survey to assess the opinions and experiences of transplant center staff related to processes of care graduation. METHODS Following IRB approval, medical staff at U.S. adult kidney transplant programs were surveyed using the Qualtrics survey platform (4/5/2022-10/05/2022). Respondents were invited via email and listservs of professional societies. If > 1 survey was submitted for a program, a selection hierarchy was utilized (e.g., prioritizing nephrologists' responses). RESULTS Respondents provided data from 46.7% of active programs (N = 92), representing 67% of the national kidney transplant volume. Most respondents (70%) were nephrologists. Full graduation to referring nephrologists was reported by 39% of transplant programs, with an additional 48% reporting partial graduation with ongoing co-management. Rationales for graduation were multifactorial, most commonly including patient travel distance (64%), maintenance of referral base (58%), continuity of care (58%), and center and/or patient burden (54%). Common reasons cited by programs for postgraduation return of care to the transplant center included worsening renal function (82%), malignancy (66%), opportunistic infection (63%), limited local nephrologist availability (60%), and pregnancy planning (57%). Additional coordinators and clinic staff were cited as needed to make transplant center perpetual care feasible by 78% of programs, with 71% stating that more clinicians are needed, while half thought more physical space or telemedicine are required. CONCLUSIONS Graduation of kidney transplant patients is common, with half of programs using a joint-care approach and another third reporting full return of care to the referring nephrologist. Expanded opportunities related to transplant care for the broad nephrology community are essential.
Collapse
Affiliation(s)
| | | | - Neeraj Singh
- Willis-Knighton Health System, Shreveport, Louisiana, USA
| | - Tarek Alhamad
- Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Roy D Bloom
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Gary Singer
- Midwest Nephrology Associates, Saint Peters, Missouri, USA
| | - Mona Doshi
- University of Michigan, Ann Arbor, Michigan, USA
| | | | | | | | - Caroline Wagner
- Saint Louis University Transplant Center, SSM Health Saint Louis University Hospital, St. Louis, Missouri, USA
| | - Huiling Xiao
- Saint Louis University Transplant Center, SSM Health Saint Louis University Hospital, St. Louis, Missouri, USA
| | - Krista L Lentine
- Saint Louis University Transplant Center, SSM Health Saint Louis University Hospital, St. Louis, Missouri, USA
| |
Collapse
|
|
9
|
Slominska AM, Kinsella EA, El-Wazze S, Gaudio K, Shamseddin MK, Bugeja A, Fortin MC, Farkouh M, Vinson A, Ho J, Sandal S. Losing Much More Than a Transplant: A Qualitative Study of Kidney Transplant Recipients' Experiences of Graft Failure. Kidney Int Rep 2024; 9:2937-2945. [PMID: 39430187 PMCID: PMC11489391 DOI: 10.1016/j.ekir.2024.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2024] [Revised: 06/24/2024] [Accepted: 07/08/2024] [Indexed: 10/22/2024] Open
Abstract
Introduction Kidney transplant recipients with graft failure are a growing cohort of patients who experience high morbidity and mortality. Limited evidence guides their care delivery and patient perspective to improve care processes is lacking. We conducted an in-depth exploration of how individuals experience graft failure, and the specific research question was: "What impact does the loss of an allograft have on their lives?" Methods We adopted an interpretive descriptive methodological design. Semistructured in-depth narrative interviews were conducted with adult recipients who had a history of ≥1 graft failure. Data were collected until data saturation was achieved and analyzed using an inductive and thematic approach. Results Our study included 23 participants from 6 provinces of Canada. The majority were on dialysis and not waitlisted for retransplantation (60.9%). Our thematic analysis identified that the lives of participants were impacted by a range of tangible and experiential losses that go beyond the loss of the transplant itself. The themes identified include loss of control, loss of coherence, loss of certainty, loss of hope, loss of quality of life, and loss of the transplant team. Although many perceived that graft failure was inevitable, the majority were unprepared. The confusion about eligibility for retransplantation appears to contribute to these experiences. Conclusion Individuals with graft failure experience complex mental and emotional challenges which may contribute to poor outcomes. The number of patients with graft failure globally is increasing and our findings can help guide practices aimed at supporting and guiding them toward self-management and adaptive coping.
Collapse
Affiliation(s)
- Anita Marie Slominska
- MEDIC, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Institute of Health Sciences Education, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Elizabeth Anne Kinsella
- Institute of Health Sciences Education, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Saly El-Wazze
- MEDIC, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Kathleen Gaudio
- MEDIC, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - M. Khaled Shamseddin
- Division of Nephrology, Department of Medicine, Queen’s University, Kingston, Ontario, Canada
| | - Ann Bugeja
- Division of Nephrology, Department of Medicine, Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Marie-Chantal Fortin
- Centre de recherche du Centre hospitalier de l’Université de Montréal, Montréal, Quebec, Canada
| | | | - Amanda Vinson
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Julie Ho
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Shaifali Sandal
- MEDIC, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Divisions of Nephrology and Experimental Medicine, Department of Medicine, McGill University, Montreal, Quebec, Canada
| |
Collapse
|
|
10
|
Roca-Tey R, Arcos E, Comas J, Tort J. Haemodialysis access profile in failed kidney transplant patients: Analysis of data from the Catalan Renal Registry (1998-2016). J Vasc Access 2024; 25:490-497. [PMID: 36039008 DOI: 10.1177/11297298221118738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Data about vascular access (VA) use in failed kidney transplant (KT) patients returning to haemodialysis (HD) are limited. We analysed the VA profile of these patients, the factors associated with the likelihood of HD re-initiation through fistula (AVF) and the effect of VA in use at the time of KT on kidney graft (KTx) outcome. METHOD Data from the Catalan Registry on failed KT patients restarting HD and incident HD patients with native kidney failure were examined over an 18-year period. RESULTS The VA profile of 675 failed KT patients at HD re-initiation compared with that before KT and with 16,731 incident patients starting HD was (%): AVF 79.3 versus 88.6 and 46.2 (p = 0.001 and p < 0.001), graft AVG 4.4 versus 2.6 and 1.1 (p = 0.08 and p < 0.001), tunnelled catheter TCC 12.4 versus 5.5 and 18.0 (p = 0.001 and p < 0.001) and non-tunnelled catheter 3.9 versus 3.3 and 34.7 (p = 0.56 and p < 0.001). The likelihood of HD re-initiation by AVF was significantly lower in patients with cardiovascular disease, KT duration >5 years, dialysed through AVG or TCC before KT, and females. The analysis of Kaplan-Meier curves showed a greater KTx survival in patients dialysed through arteriovenous access than in patients using catheter just before KT (λ2 = 5.59, p = 0.0181, log-rank test). Cox regression analysis showed that patients on HD through arteriovenous access at the time of KT had lower probability of KTx loss compared to those with catheter (hazard ratio 0.71, 95% CI 0.55-0.90, p = 0.005). CONCLUSIONS The VA profile of failed KT patients returning to HD and incident patients starting HD was different. Compared to before KT, the proportion of failed KT patients restarting HD with AVF decreased significantly at the expense of TCC. Patients on HD through arteriovenous access at the time of KT showed greater KTx survival compared with those using catheter.
Collapse
Affiliation(s)
- Ramon Roca-Tey
- Department of Nephrology, Hospital Universitari Mollet, Fundació Sanitària Mollet, Barcelona, Spain
| | - Emma Arcos
- Registre de Malalts Renals de Catalunya (RMRC), Organització Catalana de Trasplantaments (OCATT), Barcelona, Spain
| | - Jordi Comas
- Registre de Malalts Renals de Catalunya (RMRC), Organització Catalana de Trasplantaments (OCATT), Barcelona, Spain
| | - Jaume Tort
- Registre de Malalts Renals de Catalunya (RMRC), Organització Catalana de Trasplantaments (OCATT), Barcelona, Spain
| |
Collapse
|
|
11
|
Ogawa L, Beaird OE, Schaenman JM. Risk factors for infection in patients with a failed kidney allograft on immunosuppressive medications. FRONTIERS IN NEPHROLOGY 2023; 3:1149116. [PMID: 37675348 PMCID: PMC10479655 DOI: 10.3389/fneph.2023.1149116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 07/17/2023] [Indexed: 09/08/2023]
Abstract
Patients with a failing kidney allograft are often continued on immunosuppression (IS) to preserve residual kidney function and prevent allosensitization. It has been previously accepted that maintaining patients on immunosuppressive therapy results in an increased risk of infection, hospitalization, and mortality. However, as the management of IS in patients with a failed kidney allograft continues to evolve, it is important to review the data regarding associations between infection and specific immunosuppression regimens. We present a review of the literature of failed kidney allograft management and infection risk, and discuss practices for infection prevention. Fifteen studies, published from 1995 to 2022, which investigated the experience of patients with failed allograft and infection, were identified. Infection was most commonly documented as a general event, but when specified, included infections caused by Candida, Mycobacterium tuberculosis, and Aspergillus. In addition, the definition of reduced "IS" varied from decreased doses of a triple drug regimen to monotherapy, whereas others did not specify which medications patients were receiving. Despite attempts at lowering net immunosuppression, patients with failed allografts remain at risk of acquiring opportunistic and non-opportunistic infections. Although opportunistic infections secondary to IS are expected, somewhat surprisingly, it appears that the greatest risk of infection may be related to complications of dialysis. Therefore, mitigating strategies, such as planning for an arteriovenous (AV) fistula over a hemodialysis catheter placement, may reduce infection risk. Additional studies are needed to provide more information regarding the types and timing of infection in the setting of a failed kidney allograft. In addition, more data are needed regarding specific medications, doses, and timing of taper of IS to guide future patient management and inform strategies for infection surveillance and prophylaxis.
Collapse
Affiliation(s)
| | | | - Joanna M. Schaenman
- Division of Infectious Diseases, David Geffen School of Medicine at University of California—Los Angeles, Los Angeles, CA, United States
| |
Collapse
|
|
12
|
Loban K, Horton A, Robert JT, Hales L, Parajuli S, McAdams-DeMarco M, Sandal S. Perspectives and experiences of kidney transplant recipients with graft failure: A systematic review and meta-synthesis. Transplant Rev (Orlando) 2023; 37:100761. [PMID: 37120965 DOI: 10.1016/j.trre.2023.100761] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 04/10/2023] [Accepted: 04/11/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND Kidney transplant recipients with graft failure are a rapidly rising cohort of patients who experience high morbidity, mortality, and fragmented transitions of care between transplant and dialysis teams. Current approaches to improving care focus on medical and surgical interventions, increasing re-transplantation, and improving coordination between treating teams with little understanding of patient needs and perspectives. METHODS We undertook a systematic literature review of personal experiences of patients with graft failure. Six electronic and five grey literature databases were searched systematically. Of 4664 records screened 43 met the inclusion criteria. Six empirical qualitative studies and case studies were included in the final analysis. Thematic synthesis was used to combine data that included the perspectives of 31 patients with graft failure and 9 caregivers. RESULTS Using the Transition Model, we isolated three interconnected phases as patients transition through graft failure: shattering of lifestyle and plans associated with a successful transplant; physical and psychological turbulence; and re-alignment by learning adaptive strategies to move forward. Critical factors affecting coping included multi-disciplinary healthcare approaches, social support, and individual-level factors. While clinical transplant care was evaluated positively, participants identified gaps in the provision of information and psychosocial support related to graft failure. Graft failure had a profound impact on caregivers especially when they were living donors. CONCLUSIONS Our review reports patient-identified priorities for improving care and can help inform research and guideline development that strives to improve the care of patients with graft failure.
Collapse
Affiliation(s)
- Katya Loban
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada; Division of Experimental Medicine, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Anna Horton
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Jorane-Tiana Robert
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Lindsay Hales
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Sandesh Parajuli
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Mara McAdams-DeMarco
- Department of Surgery, NYU Grossman School of Medicine and NYU Langone Health, New York, NY, USA
| | - Shaifali Sandal
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada; Division of Experimental Medicine, Department of Medicine, McGill University, Montreal, Quebec, Canada; Division of Nephrology, Department of Medicine, McGill University, Montreal, Quebec, Canada.
| |
Collapse
|
|
13
|
Gaynor JJ, Tabbara MM, Ciancio G, Selvaggi G, Garcia J, Tekin A, Vianna R. The Importance Of Avoiding Time-Dependent Bias When Testing The Prognostic Value Of An Intervening Event - Two Acute Cellular Rejection Examples In Intestinal Transplantation. Am J Transplant 2023:S1600-6135(23)00308-8. [PMID: 36871628 DOI: 10.1016/j.ajt.2023.02.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 02/24/2023] [Indexed: 03/07/2023]
Abstract
In testing the prognostic value of the occurrence of an intervening event (clinical event that occurs post-transplant), 3 proper statistical methodologies for testing its prognostic value exist (time dependent covariate, landmark, and semi-Markov modelling methods). However, time-dependent bias has appeared in many clinical reports, whereby the intervening event is statistically treated as a baseline variable (as if it occurred at transplant). Using a single-center cohort of 445 intestinal transplant cases to test the prognostic value of 1st acute cellular rejection (ACR) and severe (grade of) ACR on the hazard rate of developing graft loss, we demonstrate how the inclusion of such time-dependent bias can lead to severe underestimation of the true hazard ratio (HR). The (statistically more powerful) time dependent covariate method in Cox's multivariable model yielded significantly unfavorable effects of 1st ACR (P<.0001; HR=2.492) and severe ACR (P<.0001; HR=4.531). In contrast, when using the time-dependent biased approach, multivariable analysis yielded an incorrect conclusion for the prognostic value of 1st ACR (P=.31, HR=0.877, 35.2% of 2.492) and a much smaller estimated effect of severe ACR (P=.0008; HR=1.589; 35.1% of 4.531). In conclusion, this study demonstrates the importance of avoiding time-dependent bias when testing the prognostic value of an intervening event.
Collapse
Affiliation(s)
- Jeffrey J Gaynor
- Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine; Miami, FL.
| | - Marina M Tabbara
- Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine; Miami, FL
| | - Gaetano Ciancio
- Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine; Miami, FL
| | - Gennaro Selvaggi
- Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine; Miami, FL
| | - Jennifer Garcia
- Miami Transplant Institute, Department of Pediatrics, University of Miami Miller School of Medicine; Miami, FL
| | - Akin Tekin
- Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine; Miami, FL
| | - Rodrigo Vianna
- Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine; Miami, FL
| |
Collapse
|
|
14
|
Gil-Casares B, Portolés J, López-Sánchez P, Tornero F, Marques M, Rojo-Álvarez JL. Transitions in an integrated model of renal replacement therapy in a regional health system. Nefrologia 2022; 42:438-447. [PMID: 36266230 DOI: 10.1016/j.nefroe.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 07/11/2021] [Indexed: 06/16/2023] Open
Abstract
INTRODUCTION AND OBJECTIVES The choice of renal replacement therapy (RRT) is an important decision that determines the quality of life and survival. Most patients change from one RRT modality to another to adapt RRT to clinical and psychosocial needs. This has been called «integrated model of RRT» that implies new questions about the best sequence of techniques. MATERIAL AND METHODS The study describes the impact of transitions between RRT modalities on survival using the Madrid Registry of Renal Patients (2008-2018). This study used the proportional hazards models and competitive risk models to perform an intention-to-treat (ITT), according to their 1st RRT modality and as-treated (AT) analysis, that consider also their 1st transition. RESULTS A total of 8971 patients started RRT during this period in Madrid (6.6 Million population): 7207 (80.3%) on hemodialysis (HD), 1401 (15.6%) on peritoneal dialysis (PD) and 363 (4.2%) received a pre-emptive kidney transplantation (KT). Incident HD-patients were older (HD group 65.3 years (SD 15.3) vs PD group 58.1 years (SD 14.8) vs KTX group 52 years (SD 17.2); p < 0.001) and had more comorbidities. They presented higher mortality (HD group 40.9% vs PD group 22.8% vs KTX group 8.3%, p < 0.001) and less access to a transplant (HD group 30.4% vs PD group 51.6%; p < 0.001). Transitions between dialysis techniques define different groups of patients with different clinical outcomes. Those who change from HD to PD do it earlier (HD → PD: 0.7 years (SD 1.1) vs PD → HD: 1.5 years (SD 1.4) p < 0.001), are younger (HD → PD: 53.5 years (SD 16.7) vs PD → HD: 61.6 years (SD 14.6); p < 0.001), presented less mortality (HD → PD: 24.5% vs PD → HD: 32.0%; p < 0.001) and higher access to a transplant (HD → PD: 49.4% vs PD → HD: 31.7%; p < 0.001). Survival analysis by competitive risks is essential for integrated RRT models, especially in groups such as PD patients, where 51.6% of the patients were considered as lost follow-up (received a KTX after during the first 2.5 years on PD). In this analysis, survival of patients who change from one technique to another, is more similar to the destination modality than the origin one. CONCLUSION Our data suggest that transitions between RRT-techniques describes different patients, who associate different risks, and could be analyzed in an integrated manner to define improvement actions. This approach should be incorporated into the analysis and reports of renal registries.
Collapse
Affiliation(s)
- Beatriz Gil-Casares
- Servicio de Nefrología, Hospital del Sureste, Arganda del Rey, Madrid, Spain; Departamento de Teoría de la Señal y Comunicaciones y Sistemas Telemáticos y de Computación, Universidad Rey Juan Carlos, Fuenlabrada, Madrid, Spain
| | - Jose Portolés
- Servicio de Nefrología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain; REDInREN RETIC ISCIII 16/009/009.
| | - Paula López-Sánchez
- Servicio de Nefrología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Fernando Tornero
- Servicio de Nefrología, Hospital del Sureste, Arganda del Rey, Madrid, Spain
| | - María Marques
- Servicio de Nefrología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain; REDInREN RETIC ISCIII 16/009/009
| | - José Luis Rojo-Álvarez
- Departamento de Teoría de la Señal y Comunicaciones y Sistemas Telemáticos y de Computación, Universidad Rey Juan Carlos, Fuenlabrada, Madrid, Spain
| |
Collapse
|
|
15
|
Knoll G, Campbell P, Chasse M, Fergusson D, Ramsay T, Karnabi P, Perl J, House A, Kim J, Johnston O, Mainra R, Houde I, Baran D, Treleaven D, Senecal L, Tibbles LA, Hébert MJ, White C, Karpinski M, Gill J. Immunosuppressant Medication Use in Patients with Kidney Allograft Failure: A Prospective Multi-Center Canadian Cohort Study. J Am Soc Nephrol 2022; 33:1182-1192. [PMID: 35321940 PMCID: PMC9161795 DOI: 10.1681/asn.2021121642] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 01/03/2022] [Indexed: 01/01/2023] Open
Abstract
Background: Patients with kidney transplant failure have a high risk of hospitalization and death due to infection. The optimal use of immunosuppressants after transplant failure remains uncertain and clinical practice varies widely. Methods: This prospective cohort study enrolled patients within 21 days of starting dialysis after transplant failure in 16 Canadian centers. Immunosuppressant medication use, death, hospitalized infection, rejection of the failed allograft, and panel reactive anti-HLA antibodies (PRA) were determined at 1, 3, 6 , and 12 months and bi-annually until death, repeat transplantation, or loss to follow-up. Results: The 269 study patients were followed for a median of 558 days. There were 33 deaths, 143 patients hospitalized for infection, and 21 rejections. Most patients (65%) continued immunosuppressants, 20% continued prednisone only, while 15% discontinued all immunosuppressants. In multivariable models, patients who continued immunosuppressants had a lower risk of death (HR =0.40, 95% CI, 0.17-0.93) and were not at increased risk of hospitalized infection (HR 1.81; 95% CI 0.82 to 4.0) compared to patients who discontinued all immunosuppressants or continued prednisone only. The mean class I and class II PRA increased from 11% to 27% and 25% to 47%, respectively, but did not differ by immunosuppressant use. Continuation of immunosuppressants was not protective of rejection of the failed allograft (HR 0.81, 95% CI, 0.22-2.94). Conclusions: Prolonged use of immunosuppressants greater than one year after transplant failure was not associated with a higher risk of death or hospitalized infection but was insufficient to prevent higher anti-HLA antibodies or rejection of the failed allograft.
Collapse
Affiliation(s)
- Greg Knoll
- G Knoll, Department of Medicine (Nephrology), University of Ottawa, Ottawa, Canada
| | - Patrica Campbell
- P Campbell, Department of Laboratory Medicine & Pathology, University of Alberta, Edmonton, Canada
| | - Michael Chasse
- M Chasse, Department of Medicine (Critical Care), University of Montreal Hospital Centre, Montreal, Canada
| | - Dean Fergusson
- D Fergusson, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Tim Ramsay
- T Ramsay, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Priscilla Karnabi
- P Karnabi, Clinical Epidemiology Program, Ottawa Health Research Institute, Ottawa, Canada
| | - Jeffrey Perl
- J Perl, Division of Nephrology, St Michael's Hospital, Toronto, Canada
| | - Andrew House
- A House, Department of Medicine (Nephrology), Western University, London, Canada
| | - Joe Kim
- J Kim, Institute of Health Policy, Management and Evaluation, University of Toronto Dalla Lana School of Public Health, Toronto, Canada
| | - Olwyn Johnston
- O Johnston, Division of Nephrology, The University of British Columbia, Vancouver, Canada
| | - Rahul Mainra
- R Mainra, Saskatchewan Transplant Program, Department of Medicine, University of Saskatchewan, Saskatoon, Canada
| | - Isabel Houde
- I Houde , Transplantation Unit, Renal Division, Department of Medicine, Laval University Faculty of Medicine, Quebec, Canada
| | - Dana Baran
- D Baran, Division of Nephrology and the Multi Organ Transplant Program, Royal Victoria Hospital, Montreal, Canada
| | - Darin Treleaven
- D Treleaven, Division of Nephrology, Department of Medicine, McMaster University, Hamilton, Canada
| | - Lynne Senecal
- L Senecal, Department of Nephrology, Maisonneuve-Rosemont Hospital, Montreal, Canada
| | - Lee Ann Tibbles
- L Tibbles, ALTRA Transplant Program, Southern Alberta, Department of Medicine, University of Calgary, Calgary, Canada
| | - Marie-Josée Hébert
- M Hébert, Centre de recherche, Centre Hospitalier de l'Université de Montréal, Montreal, Canada
| | - Christine White
- C White, Department of Medicine, Queen's University, Kingston, Canada
| | - Martin Karpinski
- M Karpinski, Department of Medicine, University of Manitoba, Winnipeg, Canada
| | - John Gill
- J Gill, Division of Nephrology, The University of British Columbia, Vancouver, Canada
| |
Collapse
|
|
16
|
Chaudhry D, Chaudhry A, Peracha J, Sharif A. Survival for waitlisted kidney failure patients receiving transplantation versus remaining on waiting list: systematic review and meta-analysis. BMJ 2022; 376:e068769. [PMID: 35232772 PMCID: PMC8886447 DOI: 10.1136/bmj-2021-068769] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/19/2022] [Indexed: 01/23/2023]
Abstract
OBJECTIVES To investigate the survival benefit of transplantation versus dialysis for waitlisted kidney failure patients with a priori stratification. DESIGN Systematic review and meta-analysis. DATA SOURCES Online databases MEDLINE, Ovid Embase, Web of Science, Cochrane Collection, and ClinicalTrials.gov were searched between database inception and 1 March 2021. INCLUSION CRITERIA All comparative studies that assessed all cause mortality for transplantation versus dialysis in patients with kidney failure waitlisted for transplant surgery were included. Two independent reviewers extracted the data and assessed the risk of bias of included studies. Meta-analysis was done using the DerSimonian-Laird random effects model, with heterogeneity investigated by subgroup analyses, sensitivity analyses, and meta-regression. RESULTS The search identified 48 observational studies with no randomised controlled trials (n=1 245 850 patients). In total, 92% (n=44/48) of studies reported a long term (at least one year) survival benefit associated with transplantation compared with dialysis. However, 11 of those studies identified stratums in which transplantation offered no statistically significant benefit over remaining on dialysis. In 18 studies suitable for meta-analysis, kidney transplantation showed a survival benefit (hazard ratio 0.45, 95% confidence interval 0.39 to 0.54; P<0.001), with significant heterogeneity even after subgroup/sensitivity analyses or meta-regression analysis. CONCLUSION Kidney transplantation remains the superior treatment modality for most patients with kidney failure to reduce all cause mortality, but some subgroups may lack a survival benefit. Given the continued scarcity of donor organs, further evidence is needed to better inform decision making for patients with kidney failure. STUDY REGISTRATION PROSPERO CRD42021247247.
Collapse
Affiliation(s)
- Daoud Chaudhry
- School of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Abdullah Chaudhry
- School of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Javeria Peracha
- Department of Nephrology and Transplantation, Queen Elizabeth Hospital, Edgbaston, Birmingham, UK
| | - Adnan Sharif
- Department of Nephrology and Transplantation, Queen Elizabeth Hospital, Edgbaston, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| |
Collapse
|
|
17
|
Guerraoui A, Galland R, Belkahla-Delabruyere F, Didier O, Berger V, Sauvajon P, Serve C, Zuriaga JC, Riquier F, Caillette-Beaudoin A. Design of therapeutic education workshops for home haemodialysis in a patient-centered chronic kidney diseases research: a qualitative study. BMC Nephrol 2022; 23:53. [PMID: 35109808 PMCID: PMC8812054 DOI: 10.1186/s12882-022-02683-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 01/24/2022] [Indexed: 12/02/2022] Open
Abstract
Rationale & Objective A quarter of patients do not receive any information on the modalities of renal remplacement therapy (RRT) before its initiation. In our facility, we provide therapeutic education workshops for all RRT except for home hemodialysis (HHD). The objectives of this study were to identify and describe the needs of CKD patients and caregivers for RRT with HHD and design therapeutic education workshops. Setting & participants Two sequential methods of qualitative data collection were conducted. Interviews with patients treated with HHD and doctors specialized in HHD were performed to define the interview guide followed by semi-structured interviews with the help of HHD patients from our center. Analytic approach Thematic analysis was conducted and were rooted in the principles of qualitative analysis for social scientists. Data were analyzed by two investigators. Transcribed interviews were entered into RQDA 3.6.1 software for data organization and coding purposes (Version 3.6.1). Results In total, five interviews were performed. We identified six themes related to the barriers, facilitators, and potential solutions to home dialysis therapy: (1) HHD allows autonomy and freedom with constraints, (2) safety of the care environment, (3) the caregiver and family environment, (4) patient’s experience and experiential knowledge, (5) self-care experience and impact on life, and (6) factors that impact the choice of treatment with HHD. We designed therapeutic education workshops in a group of patients and caregivers. Conclusions Our study confirmed previous results obtained in literature on the major barriers, facilitators, and potential solutions to HHD including the impact of HHD on the caregiver, the experiences of patients already treated with HHD, and the role of nurses and nephrologists in informing and educating patients. A program to develop patient-to-patient peer mentorship allowing patients to discuss their dialysis experience may be relevant. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-022-02683-0.
Collapse
Affiliation(s)
| | - Roula Galland
- Department of Nephrology-Dialysis, Calydial, Lyon, France
| | | | - Odile Didier
- Department of Nephrology-Dialysis, Calydial, Lyon, France
| | | | | | | | | | | | | |
Collapse
|
|
18
|
Ferro CJ, Berry M, Moody WE, George S, Sharif A, Townend JN. Screening for occult coronary artery disease in potential kidney transplant recipients: time for reappraisal? Clin Kidney J 2021; 14:2472-2482. [PMID: 34950460 PMCID: PMC8690093 DOI: 10.1093/ckj/sfab103] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 06/03/2021] [Indexed: 11/14/2022] Open
Abstract
Screening for occult coronary artery disease in potential kidney transplant recipients has become entrenched in current medical practice as the standard of care and is supported by national and international clinical guidelines. However, there is increasing and robust evidence that such an approach is out-dated, scientifically and conceptually flawed, ineffective, potentially directly harmful, discriminates against ethnic minorities and patients from more deprived socioeconomic backgrounds, and unfairly denies many patients access to potentially lifesaving and life-enhancing transplantation. Herein we review the available evidence in the light of recently published randomized controlled trials and major observational studies. We propose ways of moving the field forward to the overall benefit of patients with advanced kidney disease.
Collapse
Affiliation(s)
- Charles J Ferro
- Department of Renal Medicine, University Hospitals Birmingham, Birmingham, UK
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Miriam Berry
- Department of Renal Medicine, University Hospitals Birmingham, Birmingham, UK
| | - William E Moody
- Department of Cardiology, University Hospitals Birmingham, Birmingham, UK
| | - Sudhakar George
- Department of Cardiology, University Hospitals Birmingham, Birmingham, UK
| | - Adnan Sharif
- Department of Renal Medicine, University Hospitals Birmingham, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Jonathan N Townend
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Department of Cardiology, University Hospitals Birmingham, Birmingham, UK
| |
Collapse
|
|
19
|
Yanev I, Gagnon M, Cheng MP, Paraskevas S, Kumar D, Dragomir A, Sapir-Pichhadze R. Kidney Transplantation in Times of Covid-19: Decision Analysis in the Canadian Context. Can J Kidney Health Dis 2021; 8:20543581211040332. [PMID: 34540237 PMCID: PMC8447095 DOI: 10.1177/20543581211040332] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 07/26/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The coronavirus disease 2019 (COVID-19) pandemic impacted transplant programs across Canada. OBJECTIVE We evaluated the implications of delays in transplantation among Canadian end-stage kidney disease (ESKD) patients to allow pretransplant vaccination. DESIGN We used a Markov microsimulation model and ESKD patient perspective to study the effectiveness (quality-adjusted life years [QALY]) of living (LD) or deceased donor (DD) kidney transplantation followed by 2-dose SARS-CoV-2 vaccine versus delay in LD ("Delay LD") or refusal of DD offer ("Delay DD") to receive 2-dose SARS-CoV-2 vaccine pretransplant. SETTING Canadian dialysis and transplant centers. PATIENTS We simulated a 10 000-waitlisted ESKD patient cohort, which was predictively modeled for a lifetime horizon in monthly cycles. MEASUREMENTS Inputs on patient and graft survival estimates by patient, LD or DD characteristics, were extracted from the Treatment of End-Stage Organ Failure in Canada, Canadian Organ Replacement Register, 2009 to 2018. In addition, a literature review provided inputs on quality of life, SARS-CoV-2 transmissibility, new variants of concern, mortality risk, and antibody responses to 2-dose SARS-CoV-2 mRNA vaccines. METHODS We conducted base case, scenario, and sensitivity analyses to illustrate the impact of patient, donor, vaccine, and pandemic characteristics on the preferred strategy. RESULTS In the average waitlisted Canadian patient, receiving 2-dose SARS-CoV-2 vaccine post-transplant provided an effectiveness of 22.32 (95% confidence interval: 22.00-22.7) for LD and 19.34 (19.02-19.67) QALYs for DD. Delaying transplants for 6 months to allow 2-dose SARS-CoV-2 vaccine before LD and DD transplant yielded effectiveness of 22.83 (21.51-23.14) and 20.65 (20.33-20.96) QALYs, respectively. Scenario analysis suggested a benefit to short delays in DD transplants to receive 2-dose SARS-CoV-2 vaccine in waitlisted patients ≥55 years. Two-way sensitivity analysis suggested decreased effectiveness of the strategy prioritizing 2-dose SARS-CoV-2 vaccine prior to DD transplant the longer the delay and the higher the Kidney Donor Risk Index of the eventual DD transplant. When assessing the impact of SARS-CoV-2 variants of concern (infection rates ≥10-fold and associated mortality ≥3-fold vs base case), we found short delays to allow 2-dose SARS-CoV-2 vaccine administration pretransplant to be preferable. LIMITATIONS Risks associated with nosocomial exposure of LDs were not considered. There was uncertainty regarding input parameters related to SARS-CoV-2 infection, new variants, and COVID-19 severity in ESKD patients. Given rollout of population-level SARS-CoV-2 vaccination, we assumed a linear decrease in infection rates over 1 year. Proportions of patients mounting an antibody response to 2-dose SARS-CoV-2 mRNA vaccines were considered in lieu of data on vaccine efficacy in dialysis and following transplantation. Non-age-stratified annual mortality rates were used for waitlisted candidates. CONCLUSIONS Our analyses suggest that short delays allowing pretransplant vaccination offered comparable to greater effectiveness than pursuing transplantation without delay, proposing transplant candidates should be prioritized to receive at least 2 doses of SARS-CoV-2 vaccine. Our scenario and sensitivity analyses suggest that caution must be exercised when declining DD offers in patients offered low risk DD and who are likely to incur significant delays in access to transplantation. While population-level herd immunity may decrease infection risk in transplant patients, more data are required on vaccine efficacy against SARS-CoV-2 and variants of concern in ESKD, and how efficacy may be modified by a third vaccine dose, maintenance immunosuppression and timing of induction and rejection therapies.
Collapse
Affiliation(s)
- Ivan Yanev
- Centre for Outcomes Research and
Evaluation, The Research Institute of the McGill University Health Centre, Montreal,
QC, Canada
| | - Michael Gagnon
- Division of Nephrology and Multi-Organ
Transplant Program, Department of Medicine, McGill University, Montreal, QC,
Canada
| | - Matthew P. Cheng
- Division of Infectious Diseases,
Department of Medicine, McGill University Health Centre, Montréal, QC, Canada
- Division of Medical Microbiology,
Department of Laboratory and Pathology Medicine, McGill University Health Centre,
Montréal, QC, Canada
| | - Steven Paraskevas
- Division of General Surgery and
Multi-Organ Transplant Program, Department of Surgery, McGill University Health
Centre, Montréal, QC, Canada
| | - Deepali Kumar
- Transplant Infectious Diseases and
Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada
| | - Alice Dragomir
- Centre for Outcomes Research and
Evaluation, The Research Institute of the McGill University Health Centre, Montreal,
QC, Canada
| | - Ruth Sapir-Pichhadze
- Centre for Outcomes Research and
Evaluation, The Research Institute of the McGill University Health Centre, Montreal,
QC, Canada
- Division of Nephrology and Multi-Organ
Transplant Program, Department of Medicine, McGill University, Montreal, QC,
Canada
| |
Collapse
|
|
20
|
Gil-Casares B, Portolés J, López-Sánchez P, Tornero F, Marques M, Rojo-Álvarez JL. Transitions in an integrated model of renal replacement therapy in a regional health system. Nefrologia 2021; 42:S0211-6995(21)00149-1. [PMID: 34481678 DOI: 10.1016/j.nefro.2021.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 06/01/2021] [Accepted: 07/11/2021] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION AND OBJECTIVES The choice of renal replacement therapy (RRT) is an important decision that determines the quality of life and survival. Most patients change from one RRT modality to another to adapt RRT to clinical and psychosocial needs. This has been called «integrated model of RRT» that implies new questions about the best sequence of techniques. MATERIAL AND METHODS The study describes the impact of transitions between RRT modalities on survival using the Madrid Registry of Renal Patients (2008-2018). This study used the proportional hazards models and competitive risk models to perform an intention-to-treat (ITT), according to their 1st RRT modality and as-treated (AT) analysis, that consider also their 1st transition. RESULTS A total of 8971 patients started RRT during this period in Madrid (6.6 Million population): 7207 (80.3%) on hemodialysis (HD), 1401 (15.6%) on peritoneal dialysis (PD) and 363 (4.2%) received a pre-emptive kidney transplantation (KTX). Incident HD-patients were older (HD group 65.3 years (SD 15.3) vs PD group 58.1 years (SD 14.8) vs KTX group 52 years (SD 17.2); p<0.001) and had more comorbidities. They presented higher mortality (HD group 40.9% vs PD group 22.8% vs 8.3% KTX group, p<0.001) and less access to a transplant (HD group 30.4% vs DP group 51.6%; p<0.001). Transitions between dialysis techniques define different groups of patients with different clinical outcomes. Those who change from HD to PD do it earlier (HD→PD: 0.7 years (SD 1.1) vs PD→HD: 1.5 years (SD 1.4) p<0.001), are younger (HD→PD: 53.5 years (SD 16.7) vs PD→HD: 61.6 years (SD 14.6); p<0.001), presented less mortality (HD→PD: 24.5% vs PD→HD: 32.0%; p<0.001) and higher access to a transplant (HD→PD: 49.4% vs PD→HD: 31.7%; p<0.001). Survival analysis by competitive risks is essential for integrated RRT models, especially in groups such as PD patients, where 51.6% of the patients were considered as lost follow-up (received a KTX after during the first 2.5 years on PD). In this analysis, survival of patients who change from one technique to another, is more similar to the destination modality than the origin one. CONCLUSION Our data suggest that transitions between RRT-techniques describes different patients, who associate different risks, and could be analyzed in an integrated manner to define improvement actions. This approach should be incorporated into the analysis and reports of renal registries.
Collapse
Affiliation(s)
- Beatriz Gil-Casares
- Servicio de Nefrología, Hospital del Sureste, Arganda del Rey, Madrid, España; Departamento de Teoría de la Señal y Comunicaciones y Sistemas Telemáticos y de Computación, Universidad Rey Juan Carlos, Fuenlabrada, Madrid, España
| | - Jose Portolés
- Servicio de Nefrología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España; REDInREN RETIC ISCIII 16/009/009.
| | - Paula López-Sánchez
- Servicio de Nefrología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España
| | - Fernando Tornero
- Servicio de Nefrología, Hospital del Sureste, Arganda del Rey, Madrid, España
| | - María Marques
- Servicio de Nefrología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España; REDInREN RETIC ISCIII 16/009/009
| | - José Luis Rojo-Álvarez
- Departamento de Teoría de la Señal y Comunicaciones y Sistemas Telemáticos y de Computación, Universidad Rey Juan Carlos, Fuenlabrada, Madrid, España
| |
Collapse
|
|
21
|
Alhamad T, Lubetzky M, Lentine KL, Edusei E, Parsons R, Pavlakis M, Woodside KJ, Adey D, Blosser CD, Concepcion BP, Friedewald J, Wiseman A, Singh N, Chang SH, Gupta G, Molnar MZ, Basu A, Kraus E, Ong S, Faravardeh A, Tantisattamo E, Riella L, Rice J, Dadhania DM. Kidney recipients with allograft failure, transition of kidney care (KRAFT): A survey of contemporary practices of transplant providers. Am J Transplant 2021; 21:3034-3042. [PMID: 33559315 DOI: 10.1111/ajt.16523] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 01/13/2021] [Accepted: 01/20/2021] [Indexed: 01/25/2023]
Abstract
Kidney allograft failure and return to dialysis carry a high risk of morbidity. A practice survey was developed by the AST Kidney Pancreas Community of Practice workgroup and distributed electronically to the AST members. There were 104 respondents who represented 92 kidney transplant centers. Most survey respondents were transplant nephrologists at academic centers. The most common approach to immunosuppression management was to withdraw the antimetabolite first (73%), while only 12% responded they would withdraw calcineurin inhibitor (CNI) first. More than 60% reported that the availability of a living donor is the most important factor in their decision to taper immunosuppression, followed by risk of infection, risk of sensitization, frailty, and side effects of medications. More than half of respondents reported that embolization was either not available or offered to less than 10% as an option for surgical intervention. Majority reported that ≤50% of failed allograft patients were re-listed before dialysis, and less than a quarter of transplant nephrologists performed frequent visits with their patients with failed kidney allograft after they return to dialysis. This survey demonstrates heterogeneity in the care of patients with a failing allograft and the need for more evidence to guide improvements in clinical practice related to transition of care.
Collapse
Affiliation(s)
- Tarek Alhamad
- Washington University in St. Louis, Saint Louis, Missouri, USA
| | - Michelle Lubetzky
- New York Presbyterian Hospital- Weill Cornell Medicine, New York, New York, USA
| | | | - Emmanuel Edusei
- New York Presbyterian Hospital- Weill Cornell Medicine, New York, New York, USA
| | | | - Martha Pavlakis
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | - Deborah Adey
- University of California San Francisco, San Francisco, California, USA
| | | | | | | | | | - Neeraj Singh
- Willis Knighton Health System, Shreveport, Louisiana, USA
| | - Su-Hsin Chang
- Washington University in St. Louis, Saint Louis, Missouri, USA
| | - Gaurav Gupta
- Virginia Commonwealth University, Richmond, Virginia, USA
| | | | | | | | - Song Ong
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Arman Faravardeh
- SHARP Kidney and Pancreas Transplant Center, San Diego, California, USA
| | | | | | - Jim Rice
- Scripps Heath, San Diego, California, USA
| | - Darshana M Dadhania
- New York Presbyterian Hospital- Weill Cornell Medicine, New York, New York, USA
| |
Collapse
|
|
22
|
Ellison TA, Clark S, Hong JC, Frick KD, Segev DL. Potential Unintended Consequences of National Infectious Disease Screening Strategies in Deceased Donor Kidney Transplantation: A Cost-Effectiveness Analysis. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2021; 19:403-414. [PMID: 32885353 DOI: 10.1007/s40258-020-00593-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND In order to counter the lack of sufficient kidney donors, there has been interest in expanding the utilization of organs from increased infectious-risk donors. Negative nucleic acid testing of increased infectious-risk organs has been shown to increase their use as compared to only enzyme-linked immunosorbent assay negativity. However, it is not known how the expanded use of nucleic acid testing on a national scale might affect total donor utilization. OBJECTIVE The objective of this paper was to determine if a national screening policy requiring the use of nucleic acid testing in both increased infectious-risk and non-increased infectious-risk renal transplant donors would increase the donor organ pool. METHODS This study used decision-tree analysis to determine the cost-effectiveness of four US national screening policies based on an increasingly expansive use of nucleic acid testing for increased infectious-risk and non-increased infectious-risk kidneys. Parameters were taken from the literature. All costs were reported in 2020 US dollars using a Medicare payer perspective and a life-time horizon. RESULTS The use of nucleic acid screening solely for increased infectious-risk organs was the dominant strategy. Our results were robust to deterministic and probabilistic sensitivity analyses. One of the main driving factors of cost-effectiveness was the false-positive rate of nucleic acid testing. CONCLUSION Before implementing nucleic acid screening outside of increased infectious-risk organs, its false-positivity rate should be directly studied to ensure that its use does not detrimentally affect transplantation numbers, quality-adjusted life-years, and costs.
Collapse
Affiliation(s)
- Trevor A Ellison
- Department of Cardiothoracic Surgery, Mount Carmel Health System, Columbus, OH, USA.
| | - Samantha Clark
- Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle, WA, USA
| | - Jonathan C Hong
- Department of Health Policy and Management, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Kevin D Frick
- Department of Health Policy and Management, Johns Hopkins School of Public Health, Baltimore, MD, USA
- Johns Hopkins Carey Business School, Baltimore, MD, USA
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins University School of Public Health, Baltimore, MD, USA
| |
Collapse
|
|
23
|
Bonani M, Achermann R, Seeger H, Scharfe M, Müller T, Schaub S, Binet I, Huynh-Do U, Dahdal S, Golshayan D, Hadaya K, Wüthrich RP, Fehr T, Segerer S. Dialysis after graft loss: a Swiss experience. Nephrol Dial Transplant 2021; 35:2182-2190. [PMID: 32170950 DOI: 10.1093/ndt/gfaa037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 01/27/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Patients returning to dialysis after graft loss have high early morbidity and mortality. METHODS We used data from the Swiss Transplant Cohort Study to describe the current practice and outcomes in Switzerland. All patients who received a renal allograft between May 2008 and December 2014 were included. The patients with graft loss were divided into two groups depending on whether the graft loss occurred within 1 year after transplantation (early graft loss group) or later (late graft loss group). Patients with primary non-function who never gained graft function were excluded. RESULTS Seventy-seven out of 1502 patients lost their graft during follow-up, 40 within 1 year after transplantation. Eleven patients died within 30 days after allograft loss. Patient survival was 86, 81 and 74% at 30, 90 and 365 days after graft loss, respectively. About 92% started haemodialysis, 62% with definitive vascular access, which was associated with decreased mortality (hazard ratio = 0.28). At the time of graft loss, most patients were on triple immunosuppressive therapy with significant reduction after nephrectomy. One year after graft loss, 77.5% (31 of 40) of patients in the early and 43.2% (16 out of 37) in the late-loss group had undergone nephrectomy. Three years after graft loss, 36% of the patients with early and 12% with late graft loss received another allograft. CONCLUSION In summary, our data illustrate high mortality, and a high number of allograft nephrectomies and re-transplantations. Patients commencing haemodialysis with a catheter had significantly higher mortality than patients with definitive access. The role of immunosuppression reduction and allograft nephrectomy as interdependent factors for mortality and re-transplantation needs further evaluation.
Collapse
Affiliation(s)
- Marco Bonani
- Division of Nephrology, University Hospital Zürich, Zürich, Switzerland
| | - Rita Achermann
- Department Transplant Immunology and Nephrology, University Basel Hospital, Basel, Switzerland
| | - Harald Seeger
- Division of Nephrology, University Hospital Zürich, Zürich, Switzerland
| | - Michael Scharfe
- Department of Clinical Research, Clinical Trial Unit, University Basel Hospital, Basel, Switzerland
| | - Thomas Müller
- Division of Nephrology, University Hospital Zürich, Zürich, Switzerland
| | - Stefan Schaub
- Department of Clinical Research, Clinical Trial Unit, University Basel Hospital, Basel, Switzerland
| | - Isabelle Binet
- Division of Nephrology/Transplantation Medicine, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Uyen Huynh-Do
- Department of Nephrology and Hypertension, University of Bern, Bern, Switzerland
| | - Suzan Dahdal
- Department of Nephrology and Hypertension, University of Bern, Bern, Switzerland
| | - Dela Golshayan
- Transplantation Center, CHUV University Hospital, Lausanne, Switzerland
| | - Karine Hadaya
- Division of Nephrology, Geneva University Hospital, Geneva, Switzerland
| | - Rudolf P Wüthrich
- Division of Nephrology, University Hospital Zürich, Zürich, Switzerland
| | - Thomas Fehr
- Department of Internal Medicine, Kantonsspital Graubünden, Chur, Switzerland
| | - Stephan Segerer
- Division of Nephrology, University Hospital Zürich, Zürich, Switzerland.,Division of Nephrology, Dialysis and Transplantation, Kantonsspital Aarau, Aarau, Switzerland
| |
Collapse
|
|
24
|
Approach to stable angina in patients with advanced chronic kidney disease. Curr Opin Nephrol Hypertens 2021; 30:339-345. [PMID: 33767062 DOI: 10.1097/mnh.0000000000000709] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW Chronic kidney disease is one of the major risk factors for coronary artery disease. Both end-stage renal disease (ESRD) and advanced chronic kidney disease patients have atypical presentations of coronary artery disease (CAD) due to modifications in cardinal symptoms and clinical presentation. Data on evaluation and management of coronary artery or stable angina is limited in advanced chronic kidney disease (CKD) patients due to a limited number of trials. There are sparse data supporting either percutaneous coronary intervention (PCI) or coronary artery bypass graft in advanced CKD patients. RECENT FINDINGS The ISCHEMIA-CKD trial to date is the most extensive prospective randomized study looking at advanced CKD patients study looking at advanced CKD stage 4/5 patients randomized to medical treatment alone vs. invasive strategy for moderate to severe myocardial ischemia. There was no evidence found that an initial invasive strategy compared with conservative strategy with maximal medical management resulted in reduced risk of death or nonfatal myocardial infarction in patients with advanced CKD and coronary artery disease with stable angina. SUMMARY In this review, we will discuss the existing data on assessment and management of stable coronary artery disease/stable angina. And how this extrapolates to the application in advanced CKD patients awaiting kidney transplant.
Collapse
|
|
25
|
Van Loon E, Senev A, Lerut E, Coemans M, Callemeyn J, Van Keer JM, Daniëls L, Kuypers D, Sprangers B, Emonds MP, Naesens M. Assessing the Complex Causes of Kidney Allograft Loss. Transplantation 2021; 104:2557-2566. [PMID: 32091487 DOI: 10.1097/tp.0000000000003192] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Although graft loss is a primary endpoint in many studies in kidney transplantation and a broad spectrum of risk factors has been identified, the eventual causes of graft failure in individual cases remain ill studied. METHODS We performed a single-center cohort study in 1000 renal allograft recipients, transplanted between March 2004 and February 2013. RESULTS In total, 365 graft losses (36.5%) were identified, of which 211 (57.8%) were due to recipient death with a functioning graft and 154 (42.2%) to graft failure defined as return to dialysis or retransplantation. The main causes of recipient death were malignancy, infections, and cardiovascular disease. The main causes of graft failure were distinct for early failures, where structural issues and primary nonfunction prevailed, compared to later failures with a shift towards chronic injury. In contrast to the main focus of current research efforts, pure alloimmune causes accounted for only 17.5% of graft failures and only 7.4% of overall graft losses, although 72.7% of cases with chronic injury as presumed reason for graft failure had prior rejection episodes, potentially suggesting that alloimmune phenomena contributed to the chronic injury. CONCLUSIONS In conclusion, this study provides better insight in the eventual causes of graft failure, and their relative contribution, highlighting the weight of nonimmune causes. Future efforts aimed to improve outcome after kidney transplantation should align with the relative weight and expected impact of targeting these causes.
Collapse
Affiliation(s)
- Elisabet Van Loon
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Aleksandar Senev
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Histocompatibility and Immunogenetic Laboratory, Red Cross-Flanders, Mechelen, Belgium
| | - Evelyne Lerut
- Department of Imaging and Pathology, KU Leuven, Leuven, Belgium.,Department of Pathology, University Hospitals Leuven, Leuven, Belgium
| | - Maarten Coemans
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Leuven Biostatistics and Statistical Bioinformatics Centre, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Jasper Callemeyn
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Jan M Van Keer
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Liesbeth Daniëls
- Histocompatibility and Immunogenetic Laboratory, Red Cross-Flanders, Mechelen, Belgium
| | - Dirk Kuypers
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Ben Sprangers
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium.,Department of Microbiology and Immunology, Laboratory of Molecular Immunology, Rega Institute, KU Leuven, Leuven, Belgium
| | - Marie-Paule Emonds
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Histocompatibility and Immunogenetic Laboratory, Red Cross-Flanders, Mechelen, Belgium
| | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| |
Collapse
|
|
26
|
Requião-Moura LR, Albino CRM, Bicalho PR, Ferraz ÉDA, Pires LMDMB, da Silva MFR, Pacheco-Silva A. Long-term outcomes after kidney transplant failure and variables related to risk of death and probability of retransplant: Results from a single-center cohort study in Brazil. PLoS One 2021; 16:e0245628. [PMID: 33471845 PMCID: PMC7816974 DOI: 10.1371/journal.pone.0245628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 01/04/2021] [Indexed: 11/19/2022] Open
Abstract
Background Returning to dialysis after kidney graft loss (GL) is associated with a high risk of mortality, mainly in the first 3–6 months. The follow-up of patients with GL should be extended to better understand crude patient outcomes, mainly in emerging countries, where the transplantation activity has increased. Methods This is a historical single-center cohort study conducted in an emerging country (Brazil) that included 115 transplant patients with kidney allograft failure who were followed for 44.1 (21.4; 72.6) months after GL. The outcomes were death or retransplantation after GL calculated by Kaplan-Meier and log-rank tests. Proportional hazard ratios for death and retransplantation were assessed by Cox regression. Results The 5-year probability of retransplantation was 38.7% (95% CI: 26.1%-51.2%) and that of death was 37.7% (95% CI: 24.9%-50.5%); OR = 1.03 (95% CI: 0.71–1.70) and P = 0.66. The likelihood of retransplantation was higher in patients who resumed dialysis with higher levels of hemoglobin (HR = 1.22; 95% CI = 1.04–1.43; P = 0.01) and lower in blood type O patients (HR = 0.48; 95% CI = 0.25–0.93; P = 0.03), which was associated with a lower frequency of retransplantation with a subsequent living-donor kidney. On the other hand, the risk of death was significantly associated with Charlson comorbidity index (HR for each point = 1.37; 95% CI 1.19–1.50; P<0.001), and residual eGFR at the time when patients had resumed to dialysis (HR for each mL = 1.14; 95% CI = 1.05–1.25; P = 0.002). The trend toward a lower risk of death when patients had resumed to dialysis using AV fistula access was observed (HR = 0.50; 95% CI 0.25–1.02; P = 0.06), while a higher risk seems to be associated with the number of previous engraftment (HR = 2.01; 95% CI 0.99–4.07; P = 0.05). Conclusions The 5-year probability of retransplantation was not less than that of death. Variables related to the probability of retransplantation were hemoglobin level before resuming dialysis and ABO blood type, while the risk of death was associated with comorbidities and residual eGFR.
Collapse
Affiliation(s)
- Lúcio R. Requião-Moura
- Renal Transplant Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Nephrology Division, Federal University of São Paulo, São Paulo, Brazil
- * E-mail:
| | | | | | | | | | | | - Alvaro Pacheco-Silva
- Renal Transplant Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Nephrology Division, Federal University of São Paulo, São Paulo, Brazil
| |
Collapse
|
|
27
|
Abstract
Although overall donation and transplantation activity is higher in Europe than on other continents, differences between European countries in almost every aspect of transplantation activity (for example, in the number of transplantations, the number of people with a functioning graft, in rates of living versus deceased donation, and in the use of expanded criteria donors) suggest that there is ample room for improvement. Herein we review the policy and clinical measures that should be considered to increase access to transplantation and improve post-transplantation outcomes. This Roadmap, generated by a group of major European stakeholders collaborating within a Thematic Network, presents an outline of the challenges to increasing transplantation rates and proposes 12 key areas along with specific measures that should be considered to promote transplantation. This framework can be adopted by countries and institutions that are interested in advancing transplantation, both within and outside the European Union. Within this framework, a priority ranking of initiatives is suggested that could serve as the basis for a new European Union Action Plan on Organ Donation and Transplantation.
Collapse
|
|
28
|
Foster BJ. Survival improvements for Europeans with ESKD. Kidney Int 2020; 98:834-836. [PMID: 32998814 DOI: 10.1016/j.kint.2020.05.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 05/29/2020] [Indexed: 10/23/2022]
Abstract
Excess end-stage kidney disease-related mortality rates have decreased substantially over time among adults recorded in the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry, with the largest relative decreases in the youngest adults and the largest absolute decreases in the oldest adults. While improvements were observed among patients of all ages being treated with dialysis, patients with kidney transplants showed no clear improvements, and those ≥65 years old showed a worrying increase in excess mortality over time.
Collapse
Affiliation(s)
- Bethany J Foster
- Department of Pediatrics, McGill University, Montreal, Quebec, Canada; Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada; Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada.
| |
Collapse
|
|
29
|
Bisigniano L, Laham G, Giordani MC, Tagliafichi V, Hansen Krogh D, Maceira A, Rosa-Diez GJ. Reduced survival in patients who return to dialysis after kidney allograft failure. Clin Transplant 2020; 34:e14014. [PMID: 32567723 DOI: 10.1111/ctr.14014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 05/25/2020] [Accepted: 06/04/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND The outcome of patients who return to dialysis after Kidney allograft failure (KAF) remains unclear. Our aim was to compare the outcome of KAF patients vs two different types of transplant naive incident dialysis (TNID) patients, those on the waiting list (WL) and those with a kidney transplant contraindication (KTC). METHODS We performed an observational study using data from the Argentinian Dialysis Registry between 2005 and 2016. We compare mortality between KAF, WL, and KTC. RESULTS We included 75 722 patients of which 2734 were KAF. Survival between the three cohorts (KAF vs WL (n = 14 630) vs KTC (n = 58 358) revealed a significant difference (log-rank test: P < .0001) indicating worse survival for KTC patients and best survival for WL. We found that KAF patients had as poor outcome as KTC patients after multivariate adjustment. Cox regression showed that age >65 years: HR: 1.845 (1.79-1.89) P < .0001, transient catheter: HR: 1.303 (1.26-1.34) P < .0001, diabetic: HR: 1.273 (1.22-1.31) P < .0001, hepatitis C: HR: 1.156 (1.09-1.22) P < .0001, and albumin: HR: 1.247 (1.21-1.28) P < .0001 were associated with mortality. CONCLUSION Patients who return to dialysis after KAF have higher mortality than WL patients and similar to KTC patients.
Collapse
Affiliation(s)
- Liliana Bisigniano
- Instituto Nacional Central Único Coordinador de Ablación e Implante (INCUCAI), Buenos Aires, Argentina
| | - Gustavo Laham
- Department of Internal Medicine, Nephrology Section, Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Buenos Aires, Argentina
| | - Maria Cora Giordani
- Nephrology Division, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Viviana Tagliafichi
- Instituto Nacional Central Único Coordinador de Ablación e Implante (INCUCAI), Buenos Aires, Argentina
| | - Daniela Hansen Krogh
- Instituto Nacional Central Único Coordinador de Ablación e Implante (INCUCAI), Buenos Aires, Argentina
| | - Alberto Maceira
- Instituto Nacional Central Único Coordinador de Ablación e Implante (INCUCAI), Buenos Aires, Argentina
| | | |
Collapse
|
|
30
|
Fiorentino M, Gallo P, Giliberti M, Colucci V, Schena A, Stallone G, Gesualdo L, Castellano G. Management of patients with a failed kidney transplant: what should we do? Clin Kidney J 2020; 14:98-106. [PMID: 33564409 PMCID: PMC7857798 DOI: 10.1093/ckj/sfaa094] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 02/10/2020] [Indexed: 12/18/2022] Open
Abstract
The number of kidney transplant recipients returning to dialysis after graft failure is steadily increasing over time. Patients with a failed kidney transplant have been shown to have a significant increase in mortality compared with patients with a functioning graft or patients initiating dialysis for the first time. Moreover, the risk for infectious complications, cardiovascular disease and malignancy is greater than in the dialysis population due to the frequent maintenance of low-dose immunosuppression, which is required to reduce the risk of allosensitization, particularly in patients with the prospect of retransplantation from a living donor. The management of these patients present several controversial opinions and clinical guidelines are lacking. This article aims to review the leading evidence on the main issues in the management of patients with failed transplant, including the ideal timing and modality of dialysis reinitiation, the indications for an allograft nephrectomy or the correct management of immunosuppression during graft failure. In summary, retransplantation is a feasible option that should be considered in patients with graft failure and may help to minimize the morbidity and mortality risk associated with dialysis reinitiation.
Collapse
Affiliation(s)
- Marco Fiorentino
- Department of Emergency and Organ Transplantation, "Aldo Moro" University, Bari, Italy
| | - Pasquale Gallo
- Department of Emergency and Organ Transplantation, "Aldo Moro" University, Bari, Italy
| | - Marica Giliberti
- Department of Emergency and Organ Transplantation, "Aldo Moro" University, Bari, Italy
| | - Vincenza Colucci
- Department of Emergency and Organ Transplantation, "Aldo Moro" University, Bari, Italy
| | - Antonio Schena
- Department of Emergency and Organ Transplantation, "Aldo Moro" University, Bari, Italy
| | - Giovanni Stallone
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Science, University of Foggia, Foggia, Italy
| | - Loreto Gesualdo
- Department of Emergency and Organ Transplantation, "Aldo Moro" University, Bari, Italy
| | - Giuseppe Castellano
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Science, University of Foggia, Foggia, Italy
| |
Collapse
|
|
31
|
Sarnak MJ, Amann K, Bangalore S, Cavalcante JL, Charytan DM, Craig JC, Gill JS, Hlatky MA, Jardine AG, Landmesser U, Newby LK, Herzog CA, Cheung M, Wheeler DC, Winkelmayer WC, Marwick TH. Chronic Kidney Disease and Coronary Artery Disease: JACC State-of-the-Art Review. J Am Coll Cardiol 2020; 74:1823-1838. [PMID: 31582143 DOI: 10.1016/j.jacc.2019.08.1017] [Citation(s) in RCA: 411] [Impact Index Per Article: 82.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 07/26/2019] [Accepted: 08/16/2019] [Indexed: 12/19/2022]
Abstract
Chronic kidney disease (CKD) is a major risk factor for coronary artery disease (CAD). As well as their high prevalence of traditional CAD risk factors, such as diabetes and hypertension, persons with CKD are also exposed to other nontraditional, uremia-related cardiovascular disease risk factors, including inflammation, oxidative stress, and abnormal calcium-phosphorus metabolism. CKD and end-stage kidney disease not only increase the risk of CAD, but they also modify its clinical presentation and cardinal symptoms. Management of CAD is complicated in CKD patients, due to their likelihood of comorbid conditions and potential for side effects during interventions. This summary of the Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference on CAD and CKD (including end-stage kidney disease and transplant recipients) seeks to improve understanding of the epidemiology, pathophysiology, diagnosis, and treatment of CAD in CKD and to identify knowledge gaps, areas of controversy, and priorities for research.
Collapse
Affiliation(s)
- Mark J Sarnak
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts.
| | - Kerstin Amann
- Department of Nephropathology, University Hospital Erlangen, Erlangen, Germany
| | - Sripal Bangalore
- Division of Cardiology, New York University School of Medicine, New York, New York
| | | | - David M Charytan
- Division of Nephrology, New York University School of Medicine, New York, New York
| | - Jonathan C Craig
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - John S Gill
- Division of Nephrology, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mark A Hlatky
- Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California
| | - Alan G Jardine
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Ulf Landmesser
- Department of Cardiology, Charité Universitätsmedizin, Berlin, Germany
| | - L Kristin Newby
- Division of Cardiology, Department of Medicine and Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Charles A Herzog
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota; Chronic Disease Research Group, Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - Michael Cheung
- Kidney Disease: Improving Global Outcomes, Brussels, Belgium
| | | | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Thomas H Marwick
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia.
| |
Collapse
|
|
32
|
Ghahrodi MS, Einollahi B, Baharvand A, Javanbakht M. Assessment of Short-term, Within Hospital Cardiovascular Complications After Renal Transplantation in Baqiyatallah Hospital. Mater Sociomed 2020; 31:241-245. [PMID: 32082086 PMCID: PMC7007615 DOI: 10.5455/msm.2019.31.241-245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Introduction: Several studies have looked at cardiac complications in patients with end-stage renal disease (ESRD) after renal transplantation, but more attention has been paid to the long-term cardiovascular complications. Aim: The present study was designed to investigate the short-term cardiovascular complications of intrahospital hospitalization in post-renal transplant patients and related factors. Methods: In this retrospective cohort study, the medical records of all renal transplant patients in Baqiyatallah Hospital between 2015 and 2018 during the post-transplantation phase were investigated. Demographic data, transplantation type, cardiac risk factors, pre-operation cardiac consultation and para-clinical tests results were extracted from the patients’ records. The frequency and factors influencing the need for re-visitation as well as its final diagnosis were analyzed. Results: A total of 982 patients with a mean age of 13.73 ± 45.33 years were studied (62.6% males). In 39.8% of patients, cardiology re-visitation was required; of these 391 visits, only 162 patients (41.4%) had heart problems. In multivariate analysis, patients’ need for cardiac reconsideration was predicted by 7 variables; age, diabetes, history of CABG, ECG, echocardiography, angiography, and myocardial perfusion scan (R2 = 0.652, P <0.001). Furthermore, the five variables of first cardiology consultant, the first consultation physician, left ventricular hypertrophy, having history of angiography and myocardial perfusion scan, can predict the final diagnosis of cardiac problems in re-counseling (R2 = 0.188, P = 0.043). Conclusion: Given the high prevalence of need for a patient’s recurrent cardiac visit, it seems that risk assessment prior to kidney transplantation needs to be more accurate. It is recommended that elderly patients with abnormal findings in electrocardiography and echocardiography, having diabetes, having a history of negative coronary angiography or myocardial perfusion scan be more closely monitored for heart disease.
Collapse
Affiliation(s)
- Mohsen Sadeghi Ghahrodi
- Department of Cardiology, School of Medicine, Baqiyatallah University of Medical Sciences, Tehran, Iran.,Atherosclerosis Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Behzad Einollahi
- Nephrology and Urology Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Amir Baharvand
- Department of Cardiology, School of Medicine, Baqiyatallah University of Medical Sciences, Tehran, Iran.,Atherosclerosis Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Mohammad Javanbakht
- Nephrology and Urology Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| |
Collapse
|
|
33
|
The Causes of Kidney Allograft Failure: More Than Alloimmunity. A Viewpoint Article. Transplantation 2020; 104:e46-e56. [DOI: 10.1097/tp.0000000000003012] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
|
34
|
Varas J, Pérez-Sáez MJ, Ramos R, Merello JI, de Francisco ALM, Luño J, Praga M, Aljama P, Pascual J. Returning to haemodialysis after kidney allograft failure: a survival study with propensity score matching. Nephrol Dial Transplant 2020; 34:667-672. [PMID: 30053152 DOI: 10.1093/ndt/gfy215] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Patients who return to dialysis after kidney allograft failure (KAF) are classically considered to have lower survival rates than their transplant-naïve incident dialysis counterparts. However, this observation in previous comparisons could be due to poor matching between the two populations. METHODS To compare survival rates between patients who returned to haemodialysis (HD) after KAF versus transplant-naïve incident HD patients, we performed a retrospective study using the EuCliD® database (European Clinical Database) that collects data from Fresenius Medical Care (FMC) outpatient HD facilities in Spain. Propensity score matching (PSM) was performed to homogenize both populations. RESULTS This study included 5216 patients from 65 different FMC clinics between 2009 and 2014. Naïve incident HD patients were mostly male, older, comorbid and more commonly had catheters as vascular access. During the study follow-up, 3915 patients exited, of whom 1534 died. The mean survival time for the entire cohort was 4.86 years [95% confidence interval (CI) 4.78-4.94]. Univariate Cox analysis indicated higher mortality risk among transplant-naïve incident HD patients [hazard ratio (HR) 1.728; 95% CI 1.35-2.21; P < 0.001). However, this difference was no longer significant after multivariate adjustment. After applying PSM to minimize the bias due to indication issue, we obtained an adjusted population composed of 480 naïve and 240 KAF patients. The results analysing the PSM-adjusted cohort confirmed similar survival in both cohorts (log-rank, 3.34; P = 0.068; HR 1.382; 95% CI 0.97-1.95; P = 0.069). CONCLUSIONS When comparing properly matched patient groups, patients who return to HD after KAF present similar survival than survival than transplant-naïve incident patients.
Collapse
Affiliation(s)
- Javier Varas
- Medical Direction, Fresenius Medical Care, Madrid, Spain
| | | | - Rosa Ramos
- Medical Direction, Fresenius Medical Care, Madrid, Spain
| | | | | | - José Luño
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,RedInRen, Instituto de Salud Carlos III, Córdoba, Spain
| | - Manuel Praga
- RedInRen, Instituto de Salud Carlos III, Córdoba, Spain.,Department of Nephrology, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Pedro Aljama
- RedInRen, Instituto de Salud Carlos III, Córdoba, Spain.,Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, Spain.,Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Julio Pascual
- Department of Nephrology, Hospital del Mar, Barcelona, Spain.,RedInRen, Instituto de Salud Carlos III, Córdoba, Spain
| | | |
Collapse
|
|
35
|
Beaudreuil S, Iglicki F, Ledoux S, Elias M, Obada ENN, Hebibi H, Durand E, Charpentier B, Coffin B, Durrbach A. Efficacy and Safety of Intra-gastric Balloon Placement in Dialyzed Patients Awaiting Kidney Transplantation. Obes Surg 2019; 29:713-720. [PMID: 30474792 DOI: 10.1007/s11695-018-3574-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The number of obese patients who are candidates for renal transplantation has considerably increased, but obesity can be a barrier to kidney transplantation. Weight loss is often difficult through diet alone. We studied the efficacy and tolerance of the intra-gastric balloon (IGB) procedure in obese patients who were undergoing dialysis and were candidates for a renal transplantation. PATIENTS AND METHODS Obese patients (BMI > 30 kg/m2) who were candidates for renal transplantation were prospectively included in the study between 2010 and 2012. The balloon was inserted and removed during a gastric endoscopy under general anesthesia. The treatment lasted 6 months. The end point was a decrease in BMI after 6 months. Body impedance spectrometry (BIS) and nutritional statute were evaluated initially and then after IGB removal. RESULTS Seventeen patients (nine females and eight males) with a mean age of 53.4 years [19.4-69.4] were included. The decrease in body mass index (BMI) during the 6-month placement was 3 kg/m2 (from 37.7 to 34.4 kg/m2). The mean weight loss was 7 kg. The mean percentage of excess weight loss after 6 months was 20.2 (± 11.4). The tolerance was good without any complications. Eleven patients underwent kidney transplantation. CONCLUSION IGB in obese dialyzed patients who are candidates for renal transplantation is safe and effective. However, the amount of weight loss can vary.
Collapse
Affiliation(s)
- Séverine Beaudreuil
- Department of Nephrology Dialysis, Transplantation, IFRNT, University of Paris-Sud, Le Kremlin Bicetre, France. .,INSERM UMRS1197, Villejuif, France.
| | - Franck Iglicki
- Gastroenterology Unit, AP-HP, Louis Mourier Hospital and Denis Diderot University Paris 7, Paris, France
| | - Séverine Ledoux
- Service des Explorations Fonctionnelles and Centre Intégré Nord Francilien de prise en charge de l'Obésité (CINFO), Hôpital Louis Mourier (AP-HP) and Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Michelle Elias
- Department of Nephrology Dialysis, Transplantation, IFRNT, University of Paris-Sud, Le Kremlin Bicetre, France
| | - Erika NNang Obada
- Department of Nephrology Dialysis, Transplantation, IFRNT, University of Paris-Sud, Le Kremlin Bicetre, France
| | - Hadia Hebibi
- Department of Nephrology Dialysis, Transplantation, IFRNT, University of Paris-Sud, Le Kremlin Bicetre, France
| | - Emmanuel Durand
- IR4M (UMR8081), 91405 Univ Paris Sud, Univ Paris Saclay, Department of Nuclear Medicine, Hôpitaux Universitaires Paris Sud, Paris, France
| | - Bernard Charpentier
- Department of Nephrology Dialysis, Transplantation, IFRNT, University of Paris-Sud, Le Kremlin Bicetre, France.,INSERM UMRS1197, Villejuif, France
| | - Benoit Coffin
- Gastroenterology Unit, AP-HP, Louis Mourier Hospital and Denis Diderot University Paris 7, Paris, France
| | - Antoine Durrbach
- Department of Nephrology Dialysis, Transplantation, IFRNT, University of Paris-Sud, Le Kremlin Bicetre, France.,INSERM UMRS1197, Villejuif, France
| |
Collapse
|
|
36
|
Hernández D, Alonso-Titos J, Armas-Padrón AM, Lopez V, Cabello M, Sola E, Fuentes L, Gutierrez E, Vazquez T, Jimenez T, Ruiz-Esteban P, Gonzalez-Molina M. Waiting List and Kidney Transplant Vascular Risk: An Ongoing Unmet Concern. Kidney Blood Press Res 2019; 45:1-27. [PMID: 31801144 DOI: 10.1159/000504546] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 11/01/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is an important independent risk factor for adverse cardiovascular events in patients waitlisted for kidney transplantation (KT). Although KT reduces cardiovascular risk, these patients still have a higher all-cause and cardiovascular mortality than the general population. This concerning situation is due to a high burden of traditional and nontraditional risk factors as well as uremia-related factors and transplant-specific factors, leading to 2 differentiated processes under the framework of CKD, atherosclerosis and arteriosclerosis. These can be initiated by insults to the vascular endothelial endothelium, leading to vascular calcification (VC) of the tunica media or the tunica intima, which may coexist. Several pathogenic mechanisms such as inflammation-related endothelial dysfunction, mineral metabolism disorders, activation of the renin-angiotensin system, reduction of nitric oxide, lipid disorders, and the fibroblast growth factor 23-klotho axis are involved in the pathogenesis of atherosclerosis and arteriosclerosis, including VC. SUMMARY This review focuses on the current understanding of atherosclerosis and arteriosclerosis, both in patients on the waiting list as well as in kidney transplant recipients, emphasizing the cardiovascular risk factors in both populations and the inflammation-related pathogenic mechanisms. Key Message: The importance of cardiovascular risk factors and the pathogenic mechanisms related to inflammation in patients waitlisted for KT and kidney transplant recipients.
Collapse
Affiliation(s)
- Domingo Hernández
- Department of Nephrology, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain,
| | - Juana Alonso-Titos
- Department of Nephrology, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | | | - Veronica Lopez
- Department of Nephrology, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - Mercedes Cabello
- Department of Nephrology, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - Eugenia Sola
- Department of Nephrology, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - Laura Fuentes
- Department of Nephrology, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - Elena Gutierrez
- Department of Nephrology, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - Teresa Vazquez
- Department of Nephrology, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - Tamara Jimenez
- Department of Nephrology, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - Pedro Ruiz-Esteban
- Department of Nephrology, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - Miguel Gonzalez-Molina
- Department of Nephrology, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| |
Collapse
|
|
37
|
Slon Roblero MF, Borman N, Bajo Rubio MA. Integrated care: enhancing transition from renal replacement therapy options to home haemodialysis. Clin Kidney J 2019; 13:105-110. [PMID: 32082558 PMCID: PMC7025339 DOI: 10.1093/ckj/sfz140] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 09/09/2019] [Indexed: 12/18/2022] Open
Abstract
Transition is an intrinsic process in the life of a patient with kidney disease and should be planned and anticipated when possible. A single therapy option might not be adequate across a patient’s entire lifespan and many patients will require a switch in their treatment modality to adapt the treatment to their clinical and psychosocial needs. There are several reasons behind changing a patient’s treatment modality, and the consequences of each decision should be evaluated, considering both short- and long-term benefits and risks. Dialysis modality transition is not only to allow for technical optimization or improved patient survival, the patient’s experience associated with the transition should also be taken into account. Transition should not be considered as treatment failure, but rather as an expected progression in the patient’s treatment options.
Collapse
Affiliation(s)
- Maria Fernanda Slon Roblero
- Department of Nephrology, Complejo Hospitalario Navarra, Navarre, Spain.,Cardiovascular Department, IdisNa, Navarre, Spain
| | - Natalie Borman
- Wessex Renal and Transplantation Unit, Queen Alexandra Hospital, Portsmouth, Portsmouth, UK
| | - Maria Auxiliadora Bajo Rubio
- Department of Nephrology, Hospital Universitario La Paz, Madrid, Spain.,Department of Nephrology, IdiPAZ, Madrid, Spain
| |
Collapse
|
|
38
|
Ying T, Gill J, Webster A, Kim SJ, Morton R, Klarenbach SW, Kelly P, Ramsay T, Knoll GA, Pilmore H, Hughes G, Herzog CA, Chadban S, Gill JS. Canadian-Australasian Randomised trial of screening kidney transplant candidates for coronary artery disease-A trial protocol for the CARSK study. Am Heart J 2019; 214:175-183. [PMID: 31228771 DOI: 10.1016/j.ahj.2019.05.008] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Accepted: 05/13/2019] [Indexed: 01/28/2023]
Abstract
Transplantation is the preferred treatment for patients with kidney failure, but the need exceeds the supply of transplantable kidneys, and patients routinely wait >5 years on dialysis for a transplant. Coronary artery disease (CAD) is common in kidney failure and can exclude patients from transplantation or result in death before or after transplantation. Screening asymptomatic patients for CAD using noninvasive tests prior to wait-listing and at regular intervals (ie, annually) after wait-listing until transplantation is the established standard of care and is justified by the need to avoid adverse patient outcomes and loss of organs. Patients with abnormal screening tests undergo coronary angiography, and those with critical stenoses are revascularized. Screening is potentially harmful because patients may be excluded or delayed from transplantation, and complications after revascularization are more frequent in this population. CARSK will test the hypothesis that eliminating screening tests for occult CAD after wait-listing is not inferior to regular screening for the prevention of major adverse cardiac events defined as the composite of cardiovascular death, nonfatal myocardial infarction, urgent revascularization, and hospitalization for unstable angina. Secondary outcomes include the transplant rate, safety measures, and the cost-effectiveness of screening. Enrolment of 3,306 patients over 3 years is required, with patients followed for up to 5 years during wait-listing and for 1 year after transplantation. By validating or refuting the use of screening tests during wait-listing, CARSK will ensure judicious use of health resources and optimal patient outcomes.
Collapse
|
|
39
|
Clark S, Kadatz M, Gill J, Gill JS. Access to Kidney Transplantation after a Failed First Kidney Transplant and Associations with Patient and Allograft Survival: An Analysis of National Data to Inform Allocation Policy. Clin J Am Soc Nephrol 2019; 14:1228-1237. [PMID: 31337621 PMCID: PMC6682813 DOI: 10.2215/cjn.01530219] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 05/30/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVES Patients who have failed a transplant are at increased risk of repeat transplant failure. We determined access to transplantation and transplant outcomes in patients with and without a history of transplant failure. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In this observational study of national data, the proportion of waitlisted patients and deceased donor transplant recipients with transplant failure was determined before and after the new kidney allocation system. Among patients initiating maintenance dialysis between May 1995 and December 2014, the likelihood of deceased donor transplantation was determined in patients with (n=27,459) and without (n=1,426,677) a history of transplant failure. Among transplant recipients, allograft survival, the duration of additional kidney replacement therapy required within 10 years of transplantation, and the association of transplantation versus dialysis with mortality was determined in patients with and without a history of transplant failure. RESULTS The proportion of waitlist candidates (mean 14%) and transplant recipients (mean 12%) with transplant failure did not increase after the new kidney allocation system. Among patients initiating maintenance dialysis, transplant-failure patients had a higher likelihood of transplantation (hazard ratio [HR], 1.16; 95% confidence interval [95% CI], 1.12 to 1.20; P<0.001). Among transplant recipients, transplant-failure patients had a higher likelihood of death-censored transplant failure (HR, 1.44; 95% CI, 1.34 to 1.54; P<0.001) and a greater need for additional kidney replacement therapy required within 10 years after transplantation (mean, 9.0; 95% CI, 5.4 to 12.6 versus mean, 2.1; 95% CI, 1.5 to 2.7 months). The association of transplantation versus dialysis with mortality was clinically similar in waitlisted patients with (HR, 0.32; 95% CI, 0.29 to 0.35; P<0.001) and without transplant failure (HR, 0.40; 95% CI, 0.39 to 0.41; P<0.001). CONCLUSIONS Transplant-failure patients initiating maintenance dialysis have a higher likelihood of transplantation than transplant-naïve patients. Despite inferior death-censored transplant survival, transplantation was associated with a similar reduction in the risk of death compared with treatment with dialysis in patients with and without a prior history of transplant failure.
Collapse
Affiliation(s)
- Stephanie Clark
- Kidney Division, Providence Health Research Institute, Vancouver, Canada
| | | | - Jagbir Gill
- Division of Nephrology and.,Centre for Health Evaluation and Outcomes Sciences, University of British Columbia, Vancouver, Canada; and
| | - John S Gill
- Division of Nephrology and .,Centre for Health Evaluation and Outcomes Sciences, University of British Columbia, Vancouver, Canada; and.,Division of Nephrology, Tufts New England Medical Center, Boston, Massachusetts
| |
Collapse
|
|
40
|
Huml AM, Sehgal AR. Hemodialysis Quality Metrics in the First Year Following a Failed Kidney Transplant. Am J Nephrol 2019; 50:161-167. [PMID: 31311008 DOI: 10.1159/000501605] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 06/17/2019] [Indexed: 01/16/2023]
Abstract
BACKGROUND Failure of a previously transplanted kidney is a common cause of end-stage renal disease (ESRD) and represents 5% of incident dialysis patients in the United States. Patients with native kidney failure ESRD (Nat-ESRD) who receive predialysis care from a nephrologist have better outcomes in the first 12 months on dialysis than those who don't. Because many patients with a failed kidney transplant ESRD (Tx-ESRD) receive care from nephrologists, they would also be expected to have good dialysis outcomes. We sought to compare the quality metrics of Tx-ESRD patients and Nat-ESRD patients during the first 12 months of hemodialysis. METHODS We used data from the United States Renal Data System to identify hemodialysis patients who began treatment between May 2012 and December 2013 and who received nephrology care prior to starting hemodialysis. Quality metrics by quarter for the first 12 months of treatment were dichotomized according to practice guidelines to determine the percentage of patients in each quarter who met quality of care goals. RESULTS Compared to Nat-ESRD (n = 96,063) patients, Tx-ESRD (n = 5,528) patients had 10-19% lower rates of at goal hemoglobin levels, 6-12% lower rates of at goal serum phosphorus, and 3-11% lower rates of at goal albumin levels. Compared to Nat-ESRD patients, -Tx-ESRD patients had a 6% higher rate of fistula use in the first quarter but a 3-7% lower rate in subsequent quarters. CONCLUSIONS Tx-ESRD patients have worse quality metrics related to anemia, phosphorus, albumin, and vascular access compared to Nat-ESRD patients. Nephrology care for patients with Tx-ESRD should be improved to address these quality metrics gaps.
Collapse
Affiliation(s)
- Anne M Huml
- Center for Reducing Health Disparities, Case Western Reserve University, Cleveland, Ohio, USA,
- Division of Nephrology, Department of Medicine, Metro Health Medical Center, Cleveland, Ohio, USA,
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA,
| | - Ashwini R Sehgal
- Center for Reducing Health Disparities, Case Western Reserve University, Cleveland, Ohio, USA
- Division of Nephrology, Department of Medicine, Metro Health Medical Center, Cleveland, Ohio, USA
- Department of Epidemiology and Biostatistics, Case Western Reserve University Cleveland, Cleveland, Ohio, USA
| |
Collapse
|
|
41
|
Jeon HJ, Bae HJ, Ham YR, Choi DE, Na KR, Ahn MS, Lee KW. Outcomes of end-stage renal disease patients on the waiting list for deceased donor kidney transplantation: A single-center study. Kidney Res Clin Pract 2019; 38:116-123. [PMID: 30743320 PMCID: PMC6481973 DOI: 10.23876/j.krcp.18.0068] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 11/08/2018] [Accepted: 11/12/2018] [Indexed: 12/27/2022] Open
Abstract
Background Kidney transplantation is an effective renal replacement therapy for patients with end-stage renal disease (ESRD). In this study, we assessed the impact of the baseline characteristics and comorbidities of ESRD patients on the probability of deceased donor kidney transplantation (DDKT) and evaluated the morbidity and mortality during the time spent waiting. Methods The study population consisted of 544 ESRD patients on the waiting list for DDKT at Chungnam National University Hospital in South Korea between February 2000 and October 2015. The patients were observed from the date of transplantation list registration to the date of transplantation. Baseline characteristics and comorbidities were investigated together with new-onset comorbidities that occurred during the waiting time. Results Diabetes mellitus (39.0%), hypertension (25.2%), and glomerulonephritis (21.3%) were the three most common causes of ESRD in this study, and coronary artery disease (9.4%) was the most common comorbidity. The 115 patients (19.3%) who underwent DDKT had a mean waiting time of 1,711 days (768–2,654 days or 4.68 years [2.10–7.27]). Blood groups other than type O, peritoneal dialysis, and nondiabetic ESRD were significantly associated with a higher likelihood of DDKT. Infection was the leading cause of death and the most common comorbidity that arose during the waiting time. Patients who experienced cardiovascular events during the waiting time showed a lower transplant rate compared with those who did not. Conclusion The prevalence of comorbidities was high in renal transplantation candidates. During the often-long waiting time, new comorbidities may occur, with long-term sequelae limiting access to kidney transplantation or resulting in death.
Collapse
Affiliation(s)
- Hong Jae Jeon
- Division of Nephrology, Department of Internal Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Hong Jin Bae
- Division of Nephrology, Department of Internal Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Young Rok Ham
- Division of Nephrology, Department of Internal Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Dae Eun Choi
- Division of Nephrology, Department of Internal Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Ki Ryang Na
- Division of Nephrology, Department of Internal Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Moon-Sang Ahn
- Department of Surgery, Chungnam National University Hospital, Daejeon, Korea
| | - Kang Wook Lee
- Division of Nephrology, Department of Internal Medicine, Chungnam National University Hospital, Daejeon, Korea
| |
Collapse
|
|
42
|
Franco A, Moreso F, Merino E, Sancho A, Kanter J, Gimeno A, Balibrea N, Rodriguez M, Perez Contreras F. Renal transplantation from seropositive hepatitis C virus donors to seronegative recipients in Spain: a prospective study. Transpl Int 2019; 32:710-716. [PMID: 30773693 DOI: 10.1111/tri.13410] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Revised: 08/11/2018] [Accepted: 02/11/2019] [Indexed: 01/03/2023]
Abstract
Hepatitis C virus (HCV) positive donors are identified in Spain by antibody detection (HCV-Ab) techniques while a HCV nuclear acid-testing (HCV-NAT) is not mandatory. Since it has been shown that HCV-Ab positive HCV-NAT negative donors do not universally transmit the infection, we designed a protocol based on the identification of viremia in HCV-Ab positive donors to start treatment if needed. HCV-Ab-positive donors were identified and we performed HCV-NAT immediately. Donors coinfected with HIV were excluded. Recipients with a low chance to receive a transplant, with no history of liver disease and who were negative for HCV-Ab were selected after informed consent was signed. Kidney recipients from HCV-NAT-positive donors received glecaprevir and pibrentasvir from 6 h before the transplant until 8 weeks after. Recipients from HCV-NAT-negative donors were not treated. Regular monitoring by HCV-NAT was performed to initiate antiviral treatment. We included 11 recipients from six deceased donors Four recipients received grafts from HCV-NAT-positive donors and seven patients received grafts from HCV-NAT-negative donors. None of our recipients exhibited HCV-NAT positivity during the minimum follow-up period of 6 months. Recipients from HCV-NAT-positive donors exhibited sustained virologic response at 12 weeks. One recipient from an HCV-NAT-negative donor lost his graft via a process thought to be unrelated to HCV. The remaining 10 patients had a stable functioning graft at the end of the follow-up period. Our preliminary data suggest that renal transplantation from HCV-Ab- positive donors to HCV-Ab negative recipients is safe when only the recipients of organs from HCV-NAT-positive donors are treated.
Collapse
Affiliation(s)
- Antonio Franco
- Department of Nephrology, Hospital General Alicante, Alicante, Spain
| | - Francesc Moreso
- Department of Nephrology, Hospital Universitari Vall Hebron Barcelona, Barcelona, Spain
| | - Esperanza Merino
- Department of Internal Medicine, Hospital General Alicante, Alicante, Spain
| | - Asunción Sancho
- Department of Nephrology, Hospital Dr Pesset, Valencia, Spain
| | - Julia Kanter
- Department of Nephrology, Hospital Dr Pesset, Valencia, Spain
| | - Adelina Gimeno
- Department of Microbiology, Hospital General Alicante, Alicante, Spain
| | - Noelia Balibrea
- Department of Nephrology, Hospital General Alicante, Alicante, Spain
| | - Maria Rodriguez
- Department of Hepatology, Hospital General Alicante, Alicante, Spain
| | | |
Collapse
|
|
43
|
Abstract
Progress in patient care and immunosuppressive medications has resulted in improved allograft survival in the early posttransplant period; however, substantial graft loss continues in the long term. Therefore, the number of dialysis patients with failed allografts is increasing progressively. These patients have a worse prognosis than naive dialysis patients. Cardiovascular causes are the leading cause of death, followed by infections and malignancies. Delay in return to dialysis, a chronic inflammatory state, infections, and cancer are contributing factors to mortality, whereas type of dialysis modality does not have a significant effect on outcomes. Graft nephrectomy is a risky operation; therefore, it should not be a routine procedure and rather should be performed only when indicated. Overall, most grafts are left in place, whereas graft nephrectomy is performed in atients with graft intolerance syndrome. Management of immunosuppressive drugs after graft failure is controversial. In the case of maintaining immunosuppression, there is increased risk of infections, cardiovascular diseases, and malignancies and also steroid-related adverse effects. On the other hand, discontinuation of immunosuppressants may result in loss of residual allograft function and also acute graft inflammation. Together, immunosuppressive drugs are almost always discontinued in these patients because of their inherent adverse effects. Considering the sequence of cessation, first antiproliferative drugs are stopped, followed by calcineurin inhibitors, and finally steroids. Because many studies show a clear survival benefit, every attempt should be made for a retransplant in patients with failed renal allografts.
Collapse
Affiliation(s)
- Ali Riza Ucar
- From the Department of Internal Medicine, Division of Nephrology, Istanbul School of Medicine, Millet Caddesi, Capa, Istanbul, Turkey
| | | | | |
Collapse
|
|
44
|
Chowaniec Y, Luyckx F, Karam G, Glemain P, Dantal J, Rigaud J, Branchereau J. Transplant nephrectomy after graft failure: is it so risky? Impact on morbidity, mortality and alloimmunization. Int Urol Nephrol 2018; 50:1787-1793. [PMID: 30120679 DOI: 10.1007/s11255-018-1960-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 08/09/2018] [Indexed: 01/09/2023]
Abstract
PURPOSE To determine the impact of transplant nephrectomy on morbidity and mortality and HLA immunization. METHODS All patients who underwent transplant nephrectomy in our centre between 2000 and 2016 were included in this study. A total of 2822 renal transplantations and 180 transplant nephrectomies were performed during this period. RESULTS The indications for transplant nephrectomy were graft intolerance syndrome: 47.2%, sepsis: 22.2%, vascular thrombosis: 15.5%, tumour: 8.3% and other 6.8%. Transplant nephrectomies were performed via an intracapsular approach in 61.7% of cases. The blood transfusion rate was 50%, the morbidity rate was 38% and the mortality rate was 3%. Transplant nephrectomies more than 12 months after renal transplant failure were associated with more complications (p = 0.006). Transfusions in the context of transplant nephrectomy had no significant impact on alloimmunization. CONCLUSION The risk of bleeding, and therefore of transfusion, constitutes the major challenge of this surgery in patients eligible for retransplantation. Even if transfusions in this context of transplant nephrectomy had no significant impact on alloimmunization, this high-risk surgery, whenever possible, must be performed electively in a well-prepared patient.
Collapse
Affiliation(s)
- Y Chowaniec
- Institut of Transplantation, Urology and Nephrology (ITUN), CHU Nantes, 30 Bd Jean Monnet, 44035, Nantes, France
| | - F Luyckx
- Service d'Urologie, Hôpital de la Roche sur Yon, La Roche sur Yon, France
| | - G Karam
- Institut of Transplantation, Urology and Nephrology (ITUN), CHU Nantes, 30 Bd Jean Monnet, 44035, Nantes, France
| | - P Glemain
- Institut of Transplantation, Urology and Nephrology (ITUN), CHU Nantes, 30 Bd Jean Monnet, 44035, Nantes, France
| | - J Dantal
- Institut of Transplantation, Urology and Nephrology (ITUN), CHU Nantes, 30 Bd Jean Monnet, 44035, Nantes, France
| | - J Rigaud
- Institut of Transplantation, Urology and Nephrology (ITUN), CHU Nantes, 30 Bd Jean Monnet, 44035, Nantes, France
| | - J Branchereau
- Centre de Recherche en Transplantation et Immunologie UMR 1064, INSERM, Université de Nantes, Nantes, France. .,Institut of Transplantation, Urology and Nephrology (ITUN), CHU Nantes, 30 Bd Jean Monnet, 44035, Nantes, France.
| |
Collapse
|
|
45
|
Durand CM, Bowring MG, Thomas AG, Kucirka LM, Massie AB, Cameron A, Desai NM, Sulkowski M, Segev DL. The Drug Overdose Epidemic and Deceased-Donor Transplantation in the United States: A National Registry Study. Ann Intern Med 2018; 168:702-711. [PMID: 29710288 PMCID: PMC6205229 DOI: 10.7326/m17-2451] [Citation(s) in RCA: 157] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The epidemic of drug overdose deaths in the United States has led to an increase in organ donors. OBJECTIVE To characterize donors who died of overdose and to analyze outcomes among transplant recipients. DESIGN Prospective observational cohort study. SETTING Scientific Registry of Transplant Recipients, 1 January 2000 to 1 September 2017. PARTICIPANTS 138 565 deceased donors; 337 934 transplant recipients at 297 transplant centers. MEASUREMENTS The primary exposure was donor mechanism of death (overdose-death donor [ODD], trauma-death donor [TDD], or medical-death donor [MDD]). Patient and graft survival and organ discard (organ recovered but not transplanted) were compared using propensity score-weighted standardized risk differences (sRDs). RESULTS A total of 7313 ODDs and 19 897 ODD transplants (10 347 kidneys, 5707 livers, 2471 hearts, and 1372 lungs) were identified. Overdose-death donors accounted for 1.1% of donors in 2000 and 13.4% in 2017. They were more likely to be white (85.1%), aged 21 to 40 years (66.3%), infected with hepatitis C virus (HCV) (18.3%), and increased-infectious risk donors (IRDs) (56.4%). Standardized 5-year patient survival was similar for ODD organ recipients compared with TDD organ recipients (sRDs ranged from 3.1% lower to 3.9% higher survival) and MDD organ recipients (sRDs ranged from 2.1% to 5.2% higher survival). Standardized 5-year graft survival was similar between ODD and TDD grafts (minimal difference for kidneys and lungs, marginally lower [sRD, -3.2%] for livers, and marginally higher [sRD, 1.9%] for hearts). Kidney discard was higher for ODDs than TDDs (sRD, 5.2%) or MDDs (sRD, 1.5%); standardization for HCV and IRD status attenuated this difference. LIMITATION Inability to distinguish between opioid and nonopioid overdoses. CONCLUSION In the United States, transplantation with ODD organs has increased dramatically, with noninferior outcomes in transplant recipients. Concerns about IRD behaviors and hepatitis C among donors lead to excess discard that should be minimized given the current organ shortage. PRIMARY FUNDING SOURCE National Institutes of Health.
Collapse
Affiliation(s)
- Christine M Durand
- Johns Hopkins University School of Medicine, Baltimore, Maryland (C.M.D., M.G.B., A.G.T., L.M.K., A.C., N.M.D., M.S.)
| | - Mary G Bowring
- Johns Hopkins University School of Medicine, Baltimore, Maryland (C.M.D., M.G.B., A.G.T., L.M.K., A.C., N.M.D., M.S.)
| | - Alvin G Thomas
- Johns Hopkins University School of Medicine, Baltimore, Maryland (C.M.D., M.G.B., A.G.T., L.M.K., A.C., N.M.D., M.S.)
| | - Lauren M Kucirka
- Johns Hopkins University School of Medicine, Baltimore, Maryland (C.M.D., M.G.B., A.G.T., L.M.K., A.C., N.M.D., M.S.)
| | - Allan B Massie
- Johns Hopkins University School of Medicine and Johns Hopkins School of Public Health, Baltimore, Maryland (A.B.M.)
| | - Andrew Cameron
- Johns Hopkins University School of Medicine, Baltimore, Maryland (C.M.D., M.G.B., A.G.T., L.M.K., A.C., N.M.D., M.S.)
| | - Niraj M Desai
- Johns Hopkins University School of Medicine, Baltimore, Maryland (C.M.D., M.G.B., A.G.T., L.M.K., A.C., N.M.D., M.S.)
| | - Mark Sulkowski
- Johns Hopkins University School of Medicine, Baltimore, Maryland (C.M.D., M.G.B., A.G.T., L.M.K., A.C., N.M.D., M.S.)
| | - Dorry L Segev
- Johns Hopkins University School of Medicine and Johns Hopkins School of Public Health, Baltimore, Maryland, and Scientific Registry of Transplant Recipients, Minneapolis, Minnesota (D.L.S.)
| |
Collapse
|
|
46
|
Durand CM, Bowring MG, Brown DM, Chattergoon MA, Massaccesi G, Bair N, Wesson R, Reyad A, Naqvi FF, Ostrander D, Sugarman J, Segev DL, Sulkowski M, Desai NM. Direct-Acting Antiviral Prophylaxis in Kidney Transplantation From Hepatitis C Virus-Infected Donors to Noninfected Recipients: An Open-Label Nonrandomized Trial. Ann Intern Med 2018; 168:533-540. [PMID: 29507971 PMCID: PMC6108432 DOI: 10.7326/m17-2871] [Citation(s) in RCA: 238] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Given the high mortality rate for patients with end-stage kidney disease receiving dialysis and the efficacy and safety of hepatitis C virus (HCV) treatments, discarded kidneys from HCV-infected donors may be a neglected public health resource. OBJECTIVE To determine the tolerability and feasibility of using direct-acting antivirals (DAAs) as prophylaxis before and after kidney transplantation from HCV-infected donors to non-HCV-infected recipients (that is, HCV D+/R- transplantation). DESIGN Open-label nonrandomized trial. (ClinicalTrials.gov: NCT02781649). SETTING Single center. PARTICIPANTS 10 HCV D+/R- kidney transplant candidates older than 50 years with no available living donors. INTERVENTION Transplantation of kidneys from deceased donors aged 13 to 50 years with positive HCV RNA and HCV antibody test results. All recipients received a dose of grazoprevir (GZR), 100 mg, and elbasvir (EBR), 50 mg, immediately before transplantation. Recipients of kidneys from donors with genotype 1 infection continued receiving GZR-EBR for 12 weeks after transplantation; those receiving organs from donors with genotype 2 or 3 infection had sofosbuvir, 400 mg, added to GZR-EBR for 12 weeks of triple therapy. MEASUREMENTS The primary safety outcome was the incidence of adverse events related to GZR-EBR treatment. The primary efficacy outcome was the proportion of recipients with an HCV RNA level below the lower limit of quantification 12 weeks after prophylaxis. RESULTS Among 10 HCV D+/R- transplant recipients, no treatment-related adverse events occurred, and HCV RNA was not detected in any recipient 12 weeks after treatment. LIMITATION Nonrandomized study design and a small number of patients. CONCLUSION Pre- and posttransplantation HCV treatment was safe and prevented chronic HCV infection in HCV D+/R- kidney transplant recipients. If confirmed in larger studies, this strategy should markedly expand organ options and reduce mortality for kidney transplant candidates without HCV infection. PRIMARY FUNDING SOURCE Merck Sharp & Dohme.
Collapse
Affiliation(s)
- Christine M Durand
- Johns Hopkins University School of Medicine, Baltimore, Maryland (C.M.D., M.G.B., D.M.B., M.A.C., G.M., N.B., R.W., A.R., F.F.N., D.O., D.L.S., M.S., N.M.D.)
| | - Mary G Bowring
- Johns Hopkins University School of Medicine, Baltimore, Maryland (C.M.D., M.G.B., D.M.B., M.A.C., G.M., N.B., R.W., A.R., F.F.N., D.O., D.L.S., M.S., N.M.D.)
| | - Diane M Brown
- Johns Hopkins University School of Medicine, Baltimore, Maryland (C.M.D., M.G.B., D.M.B., M.A.C., G.M., N.B., R.W., A.R., F.F.N., D.O., D.L.S., M.S., N.M.D.)
| | - Michael A Chattergoon
- Johns Hopkins University School of Medicine, Baltimore, Maryland (C.M.D., M.G.B., D.M.B., M.A.C., G.M., N.B., R.W., A.R., F.F.N., D.O., D.L.S., M.S., N.M.D.)
| | - Guido Massaccesi
- Johns Hopkins University School of Medicine, Baltimore, Maryland (C.M.D., M.G.B., D.M.B., M.A.C., G.M., N.B., R.W., A.R., F.F.N., D.O., D.L.S., M.S., N.M.D.)
| | - Nichole Bair
- Johns Hopkins University School of Medicine, Baltimore, Maryland (C.M.D., M.G.B., D.M.B., M.A.C., G.M., N.B., R.W., A.R., F.F.N., D.O., D.L.S., M.S., N.M.D.)
| | - Russell Wesson
- Johns Hopkins University School of Medicine, Baltimore, Maryland (C.M.D., M.G.B., D.M.B., M.A.C., G.M., N.B., R.W., A.R., F.F.N., D.O., D.L.S., M.S., N.M.D.)
| | - Ashraf Reyad
- Johns Hopkins University School of Medicine, Baltimore, Maryland (C.M.D., M.G.B., D.M.B., M.A.C., G.M., N.B., R.W., A.R., F.F.N., D.O., D.L.S., M.S., N.M.D.)
| | - Fizza F Naqvi
- Johns Hopkins University School of Medicine, Baltimore, Maryland (C.M.D., M.G.B., D.M.B., M.A.C., G.M., N.B., R.W., A.R., F.F.N., D.O., D.L.S., M.S., N.M.D.)
| | - Darin Ostrander
- Johns Hopkins University School of Medicine, Baltimore, Maryland (C.M.D., M.G.B., D.M.B., M.A.C., G.M., N.B., R.W., A.R., F.F.N., D.O., D.L.S., M.S., N.M.D.)
| | - Jeremy Sugarman
- Johns Hopkins University School of Medicine and Johns Hopkins University, Baltimore, Maryland (J.S.)
| | - Dorry L Segev
- Johns Hopkins University School of Medicine, Baltimore, Maryland (C.M.D., M.G.B., D.M.B., M.A.C., G.M., N.B., R.W., A.R., F.F.N., D.O., D.L.S., M.S., N.M.D.)
| | - Mark Sulkowski
- Johns Hopkins University School of Medicine, Baltimore, Maryland (C.M.D., M.G.B., D.M.B., M.A.C., G.M., N.B., R.W., A.R., F.F.N., D.O., D.L.S., M.S., N.M.D.)
| | - Niraj M Desai
- Johns Hopkins University School of Medicine, Baltimore, Maryland (C.M.D., M.G.B., D.M.B., M.A.C., G.M., N.B., R.W., A.R., F.F.N., D.O., D.L.S., M.S., N.M.D.)
| |
Collapse
|
|
47
|
Hernández D, Alonso-Titos J, Armas-Padrón AM, Ruiz-Esteban P, Cabello M, López V, Fuentes L, Jironda C, Ros S, Jiménez T, Gutiérrez E, Sola E, Frutos MA, González-Molina M, Torres A. Mortality in Elderly Waiting-List Patients Versus Age-Matched Kidney Transplant Recipients: Where is the Risk? Kidney Blood Press Res 2018; 43:256-275. [PMID: 29490298 DOI: 10.1159/000487684] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 02/15/2018] [Indexed: 11/19/2022] Open
Abstract
The number of elderly patients on the waiting list (WL) for kidney transplantation (KT) has risen significantly in recent years. Because KT offers a better survival than dialysis therapy, even in the elderly, candidates for KT should be selected carefully, particularly in older waitlisted patients. Identification of risk factors for death in WL patients and prediction of both perioperative risk and long-term post-transplant mortality are crucial for the proper allocation of organs and the clinical management of these patients in order to decrease mortality, both while on the WL and after KT. In this review, we examine the clinical results in studies concerning: a) risk factors for mortality in WL patients and KT recipients; 2) the benefits and risks of performing KT in the elderly, comparing survival between patients on the WL and KT recipients; and 3) clinical tools that should be used to assess the perioperative risk of mortality and predict long-term post-transplant survival. The acknowledgment of these concerns could contribute to better management of high-risk patients and prophylactic interventions to prolong survival in this particular population, provided a higher mortality is assumed.
Collapse
Affiliation(s)
- Domingo Hernández
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, Málaga, Spain
| | - Juana Alonso-Titos
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, Málaga, Spain
| | | | - Pedro Ruiz-Esteban
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, Málaga, Spain
| | - Mercedes Cabello
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, Málaga, Spain
| | - Verónica López
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, Málaga, Spain
| | - Laura Fuentes
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, Málaga, Spain
| | - Cristina Jironda
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, Málaga, Spain
| | - Silvia Ros
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, Málaga, Spain
| | - Tamara Jiménez
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, Málaga, Spain
| | - Elena Gutiérrez
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, Málaga, Spain
| | - Eugenia Sola
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, Málaga, Spain
| | - Miguel Angel Frutos
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, Málaga, Spain
| | - Miguel González-Molina
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, Málaga, Spain
| | - Armando Torres
- Nephrology Department, Hospital Universitario de Canarias, CIBICAN, University of La Laguna, Tenerife and Instituto Reina Sofía de Investigación Renal, IRSIN, Tenerife, Spain
| |
Collapse
|
|
48
|
Hippen BE, Maddux FW. Integrating kidney transplantation into value-based care for people with renal failure. Am J Transplant 2018; 18:43-52. [PMID: 28898574 DOI: 10.1111/ajt.14454] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 07/05/2017] [Accepted: 07/29/2017] [Indexed: 01/25/2023]
Abstract
Healthcare reimbursement is increasingly tied to value instead of volume, with special attention paid to resource-intensive populations such as patients with renal disease. To this end, Medicare has sponsored pilot projects to encourage providers to develop care coordination and population health management strategies to provide quality care while reducing resource utilization. In this Personal Viewpoint essay, we argue in favor of expanding one such pilot project-the Comprehensive ESRD Care (CEC) initiative-to include patients with advanced chronic kidney disease and kidney transplant recipients. The implementation of the Medicare Access and CHIP Reauthorization Act (MACRA) offers a time-sensitive incentive for transplant centers in particular to align with extant CECs. An "expanded" CEC model proffers opportunity for robust cooperation between general nephrology practices, dialysis providers, and transplant centers to develop care coordination strategies for all patients with renal disease, realign incentives for all clinical stakeholders to increase kidney transplantation rates, and reduce total costs of care.
Collapse
|
|
49
|
Lea-Henry T, Chacko B. Management considerations in the failing renal allograft. Nephrology (Carlton) 2017; 23:12-19. [DOI: 10.1111/nep.13165] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2017] [Indexed: 12/20/2022]
Affiliation(s)
- Tom Lea-Henry
- Nephrology and Transplantation Unit; John Hunter Hospital; Newcastle New South Wales Australia
| | - Bobby Chacko
- Nephrology and Transplantation Unit; John Hunter Hospital; Newcastle New South Wales Australia
- School of Medicine and Public Health; University of Newcastle; Newcastle New South Wales Australia
| |
Collapse
|
|
50
|
Wallace EL, Rosner MH, Alscher MD, Schmitt CP, Jain A, Tentori F, Firanek C, Rheuban KS, Florez-Arango J, Jha V, Foo M, de Blok K, Marshall MR, Sanabria M, Kudelka T, Sloand JA. Remote Patient Management for Home Dialysis Patients. Kidney Int Rep 2017; 2:1009-1017. [PMID: 29634048 PMCID: PMC5733746 DOI: 10.1016/j.ekir.2017.07.010] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 07/09/2017] [Accepted: 07/24/2017] [Indexed: 12/20/2022] Open
Abstract
Remote patient management (RPM) offers renal health care providers and patients with end-stage kidney disease opportunities to embrace home dialysis therapies with greater confidence and the potential to obtain better clinical outcomes. Barriers and evidence required to increase adoption of RPM by the nephrology community need to be clearly defined. Ten health care providers from specialties including nephrology, cardiology, pediatrics, epidemiology, nursing, and health informatics with experience in home dialysis and the use of RPM systems gathered in Vienna, Austria to discuss opportunities for, barriers to, and system requirements of RPM as it applies to the home dialysis patient. Although improved outcomes and cost-effectiveness of RPM have been demonstrated in patients with diabetes mellitus and heart disease, only observational data on RPM have been gathered in patients on dialysis. The current review focused on RPM systems currently in use, on how RPM should be integrated into future care, and on the evidence needed for optimized implementation to improve clinical and economic outcomes. Randomized controlled trials and/or large observational studies could inform the most effective and economical use of RPM in home dialysis. These studies are needed to establish the value of existing and/or future RPM models among patients, policy makers, and health care providers.
Collapse
Affiliation(s)
- Eric L. Wallace
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Mitchell H. Rosner
- Division of Nephrology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Mark Dominik Alscher
- Department of Internal Medicine and Nephrology, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Claus Peter Schmitt
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Nephrology, University of Heidelberg, Heidelberg, Germany
| | - Arsh Jain
- Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada, Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada; Institute for Clinical Evaluative Sciences, London, Ontario, Canada
| | - Francesca Tentori
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Karen S. Rheuban
- Department of Center for Telehealth, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Jose Florez-Arango
- Department of Biomedical Informatics, Texas A & M University, College Station, Texas, USA
- Universidad de Pontificia Bolivariana a Escuela de Ciencias de la Salud, Medellin, Columbia
| | - Vivekanand Jha
- George Institute for Global Health, Syndey, New South Wales, Australia
| | - Marjorie Foo
- Department of Renal Medicine, Duke−National University of Singapore Graduate Medical School, Singapore
| | - Koen de Blok
- Department of Nephrology and Dialysis, Flevo Hospital, Almere, Flevoland, Netherlands
| | - Mark R. Marshall
- Baxter Healthcare (Asia) Pte Ltd, Singapore
- Counties Manukau Health, Auckland, New Zealand
| | - Mauricio Sanabria
- Baxter Healthcare Inc, Deerfield, Illinois, USA
- Renal Therapy Services, Bogota, Colombia
| | | | | |
Collapse
|