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Huml AM, Wakam GK, Schold JD. Does the Transplant System Fail Patients Following Kidney Allograft Loss? Am J Kidney Dis 2025; 85:267-269. [PMID: 39831879 DOI: 10.1053/j.ajkd.2024.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2024] [Accepted: 12/08/2024] [Indexed: 01/22/2025]
Affiliation(s)
- Anne M Huml
- Department of Kidney Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Glenn K Wakam
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jesse D Schold
- Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, Colorado; Department of Epidemiology, School of Public Health, University of Colorado, Anschutz Medical Campus, Aurora, Colorado.
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2
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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.
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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
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3
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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.
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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
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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.
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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
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Lubetzky M, Chauhan K, Alrata L, Dubrawka C, Abuazzam F, Abdulkhalek S, Abdulhadi T, Yaseen Alsabbagh D, Singh N, Lentine KL, Tanriover B, Alhamad T. Management of Failing Kidney and Pancreas Transplantations. ADVANCES IN KIDNEY DISEASE AND HEALTH 2024; 31:476-482. [PMID: 39232618 DOI: 10.1053/j.akdh.2024.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Revised: 07/02/2024] [Accepted: 07/02/2024] [Indexed: 09/06/2024]
Abstract
Survival rates for allografts have improved over the last 2 decades, yet failing allografts remains a challenge in the field of transplant. The risks of mortality and morbidity associated with failed allografts are compounded by infectious complications and metabolic abnormalities, emphasizing the need for a standardized approach to management. Management of failing allografts lacks consensus, highlighting the need for unified protocols to guide treatment protocols and minimize risks with postdialysis initiation. The decision to wean off immunosuppression depends on various factors, including living donor availability and infectious risks, necessitating improved coordination of care and a standard guideline. Treatment of failed pancreas focuses on glycemic control, with insulin as the mainstay, while considering surgical interventions such as graft pancreatectomy in advanced symptomatic cases. Navigating the complexities of failed allograft management demands a multidisciplinary approach and standardized stepwise protocol. Addressing the gaps in management plans for failing allografts and employing a systematic approach to transplant decisions will enhance patient outcomes and facilitate informed decision-making.
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Affiliation(s)
- Michelle Lubetzky
- Division of Nephrology, Department of Medicine, University of Texas in Austin, TX
| | - Krutika Chauhan
- Division of Nephrology, Department of Medicine, Washington University in St. Louis, MO
| | - Louai Alrata
- Division of Nephrology, Department of Medicine, Washington University in St. Louis, MO
| | - Casey Dubrawka
- Department of Pharmacy, Barnes Jewish Hospital, St. Louis, MO
| | - Farah Abuazzam
- Division of Nephrology, Department of Medicine, Washington University in St. Louis, MO
| | - Samer Abdulkhalek
- Division of Nephrology, Department of Medicine, Washington University in St. Louis, MO
| | - Tarek Abdulhadi
- Department of Medicine, Jamaica Hospital Medical Center, Queens, NY
| | - Dema Yaseen Alsabbagh
- Division of Nephrology, Department of Medicine, Washington University in St. Louis, MO
| | - Neeraj Singh
- Division of Nephrology, Department of Medicine, Louisiana State University in Shreveport, LA
| | - Krista L Lentine
- Division of Nephrology, Department of Medicine, Saint Louis University, MO
| | - Bekir Tanriover
- Division of Nephrology, Department of Medicine, University of Arizona College of Medicine, AZ
| | - Tarek Alhamad
- Division of Nephrology, Department of Medicine, Washington University in St. Louis, MO.
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Tran J, Alrajhi I, Chang D, Sherwood KR, Keown P, Gill J, Kadatz M, Gill J, Lan JH. Clinical relevance of HLA-DQ eplet mismatch and maintenance immunosuppression with risk of allosensitization after kidney transplant failure. Front Genet 2024; 15:1383220. [PMID: 38638120 PMCID: PMC11024336 DOI: 10.3389/fgene.2024.1383220] [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: 02/07/2024] [Accepted: 03/21/2024] [Indexed: 04/20/2024] Open
Abstract
The optimal immunosuppression management in patients with a failed kidney transplant remains uncertain. This study analyzed the association of class II HLA eplet mismatches and maintenance immunosuppression with allosensitization after graft failure in a well characterized cohort of 21 patients who failed a first kidney transplant. A clinically meaningful increase in cPRA in this study was defined as the cPRA that resulted in 50% reduction in the compatible donor pool measured from the time of transplant failure until the time of repeat transplantation, death, or end of study. The median cPRA at the time of failure was 12.13% (interquartile ranges = 0.00%, 83.72%) which increased to 62.76% (IQR = 4.34%, 99.18%) during the median follow-up of 27 (IQR = 18, 39) months. High HLA-DQ eplet mismatches were significantly associated with an increased risk of developing a clinically meaningful increase in cPRA (p = 0.02) and de novo DQ donor-specific antibody against the failed allograft (p = 0.02). We did not observe these associations in patients with high HLA-DR eplet mismatches. Most of the patients (88%) with a clinically meaningful increase in cPRA had both a high DQ eplet mismatch and a reduction in their immunosuppression, suggesting the association is modified by immunosuppression. The findings suggest HLA-DQ eplet mismatch analysis may serve as a useful tool to guide future clinical studies and trials which assess the management of immunosuppression in transplant failure patients who are repeat transplant candidates.
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Affiliation(s)
- Jenny Tran
- Department of Pathology and Laboratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Ibrahim Alrajhi
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Doris Chang
- Vancouver Coastal Health Research Institute, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Karen R. Sherwood
- Department of Pathology and Laboratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Paul Keown
- Department of Pathology and Laboratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Vancouver Coastal Health Research Institute, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Jagbir Gill
- Division of Nephrology, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Providence Health Care Research Institute, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Matthew Kadatz
- Vancouver Coastal Health Research Institute, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Division of Nephrology, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - John Gill
- Division of Nephrology, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Providence Health Care Research Institute, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - James H. Lan
- Department of Pathology and Laboratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Vancouver Coastal Health Research Institute, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Division of Nephrology, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
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7
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Bathini S, Jha V. Immunosuppressive Practices in Failed Kidney Grafts in South Asia-An Investigative Survey. Kidney Int Rep 2024; 9:1107-1110. [PMID: 38765570 PMCID: PMC11101818 DOI: 10.1016/j.ekir.2024.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 01/09/2024] [Accepted: 01/11/2024] [Indexed: 05/22/2024] Open
Affiliation(s)
| | - Vivekanand Jha
- George Institute for Global Health, UNSW, New Delhi, India
- Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
- School of Public Health, Imperial College, London, UK
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8
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Ferrari K, Aarnink A, Ayav C, Frimat L, Couchoud C, Audry B, Antoine C, Girerd S. Evolution of HLA-sensitization according to immunosuppressive therapy management among kidney transplant patients returning to dialysis between 2008 and 2019: A French retrospective study. Clin Transplant 2024; 38:e15160. [PMID: 37823237 DOI: 10.1111/ctr.15160] [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: 08/22/2022] [Revised: 08/25/2023] [Accepted: 09/29/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND The optimal management of immunosuppressive therapy (IT) after kidney allograft failure (KAF) remains controversial. Although maintaining IT may reduce HLA-sensitization and improve access to retransplantation, it may also increase the rate of immunosuppression-related complications. The overall impact on patient mortality is unknown. The main objective of this study was to compare the evolution of HLA-sensitization 6 months after KAF according to IT management. METHODS Individual clinical and health care data were extracted from the French national end-stage kidney disease registry (Renal Epidemiology and Information Network [REIN]) and the French National Health Data system (SNDS), respectively. Patients aged > 18 years returning to dialysis after KAF between January 2008 and December 2019 in Lorraine were included. Patients were classified into two groups, IT continuation or IT discontinuation. HLA-sensitization was defined as an increase in incompatible graft rate (IGR) between KAF and 6 months post-KAF (change to a higher predefined category (0%-5%), (5%-20%), (20%-50%), (50%-85%), (85%-95%), (95%-98%), (98%-100%)). Secondary outcome was patient survival according to IT management. RESULTS A total of 121 patients were included, 35 (29%) of whom continued IT. HLA-sensitization after KAF tended to be higher in the "IT discontinuation" group (57% vs. 38% in the "IT continuation" group, p = .07). In multivariate analysis, IT continuation was associated with a lower increase in IGR (OR .37, 95% CI [.14; .93]). IT management was not associated with patient mortality. CONCLUSIONS Continuation of IT after KAF was associated with less change in IGR and was not associated with excess mortality.
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Affiliation(s)
- Kevin Ferrari
- Nephrology Department, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
| | - Alice Aarnink
- Histocompatibility Laboratory, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
- IMoPA6, UMR7365 CNRS, Université de Lorraine, Vandoeuvre-les-Nancy, France
| | - Carole Ayav
- Clinical Epidemiology, Inserm CIC-EC, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
| | - Luc Frimat
- Nephrology Department, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
| | | | | | | | - Sophie Girerd
- Nephrology Department, University Hospital of Nancy, Vandoeuvre-lès-Nancy, France
- Université de Lorraine, Inserm, Centre d'Investigation Clinique-1433, and Inserm U1116, CHRU Nancy, F-CRIN INI-CRCT, Nancy, France
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9
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Casey MJ, Murakami N, Ong S, Adler JT, Singh N, Murad H, Parajuli S, Concepcion BP, Lubetzky M, Pavlakis M, Woodside KJ, Faravardeh A, Basu A, Tantisattamo E, Aala A, Gruessner AC, Dadhania DM, Lentine KL, Cooper M, Parsons RF, Alhamad T. Medical and Surgical Management of the Failed Pancreas Transplant. Transplant Direct 2024; 10:e1543. [PMID: 38094134 PMCID: PMC10715788 DOI: 10.1097/txd.0000000000001543] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 08/09/2023] [Accepted: 08/11/2023] [Indexed: 02/22/2024] Open
Abstract
Despite the continued improvements in pancreas transplant outcomes in recent decades, a subset of recipients experience graft failure and can experience substantial morbidity and mortality. Here, we summarize what is known about the failed pancreas allograft and what factors are important for consideration of retransplantation. The current definition of pancreas allograft failure and its challenges for the transplant community are explored. The impacts of a failed pancreas allograft are presented, including patient survival and resultant morbidities. The signs, symptoms, and medical and surgical management of a failed pancreas allograft are described, whereas the options and consequences of immunosuppression withdrawal are reviewed. Medical and surgical factors necessary for successful retransplant candidacy are detailed with emphasis on how well-selected patients may achieve excellent retransplant outcomes. To achieve substantial medical mitigation and even pancreas retransplantation, patients with a failed pancreas allograft warrant special attention to their residual renal, cardiovascular, and pulmonary function. Future studies of the failed pancreas allograft will require improved reporting of graft failure from transplant centers and continued investigation from experienced centers.
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Affiliation(s)
- Michael J. Casey
- Division of Nephrology, Medical University of South Carolina, Charleston, SC
| | - Naoka Murakami
- Division of Renal Medicine, Brigham and Women Hospital, Boston, MA
| | - Song Ong
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL
| | - Joel T. Adler
- Division of Transplant Surgery, University of Texas at Austin, Austin, TX
| | | | - Haris Murad
- Section of Nephrology, The Aga Khan University, Medical College, Pakistan
| | | | | | | | | | | | | | - Arpita Basu
- Division of Renal Medicine, Emory University, Atlanta, GA
| | | | - Amtul Aala
- Division of Nephrology, Beth Israel Deaconess, Boston, MA
| | | | | | - Krista L. Lentine
- Division of Nephrology, SSM Health Saint Louis University Transplant Center, St. Louis, MO
| | - Matthew Cooper
- Division of Transplant Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Ronald F. Parsons
- Division of Transplant Surgery, University of Pennsylvania, Philadelphia, PA
| | - Tarek Alhamad
- Division of Nephrology, Washington University in St Louis, St. Louis, MO
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Josephson MA, Becker Y, Budde K, Kasiske BL, Kiberd BA, Loupy A, Małyszko J, Mannon RB, Tönshoff B, Cheung M, Jadoul M, Winkelmayer WC, Zeier M. Challenges in the management of the kidney allograft: from decline to failure: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2023; 104:1076-1091. [PMID: 37236423 DOI: 10.1016/j.kint.2023.05.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 05/11/2023] [Accepted: 05/12/2023] [Indexed: 05/28/2023]
Abstract
In March 2022, Kidney Disease: Improving Global Outcomes (KDIGO) held a virtual Controversies Conference to address the important but rarely examined phase during which the kidney transplant is failing or has failed. In addition to discussing the definition of a failing allograft, 4 broad areas were considered in the context of a declining functioning graft: prognosis and kidney failure trajectory; immunosuppression strategies; management of medical and psychological complications, and patient factors; and choice of kidney replacement therapy or supportive care following graft loss. Identifying and paying special attention to individuals with failing allografts was felt to be important in order to prepare patients psychologically, manage immunosuppression, address complications, prepare for dialysis and/or retransplantation, and transition to supportive care. Accurate prognostication tools, although not yet widely available, were embraced as necessary to define allograft survival trajectories and the likelihood of allograft failure. The decision of whether to withdraw or continue immunosuppression after allograft failure was deemed to be based most appropriately on risk-benefit analysis and likelihood of retransplantation within a few months. Psychological preparation and support was identified as a critical factor in patient adjustment to graft failure, as was early communication. Several models of care were noted that enabled a medically supportive transition back to dialysis or retransplantation. Emphasis was placed on the importance of dialysis-access readiness before initiation of dialysis, in order to avoid use of central venous catheters. The centrality of the patient to all management decisions and discussions was deemed to be paramount. Patient "activation," which can be defined as engaged agency, was seen as the most effective way to achieve success. Unresolved controversies, gaps in knowledge, and areas for research were also stressed in the conference deliberations.
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Affiliation(s)
- Michelle A Josephson
- Section of Nephrology, Department of Medicine, and Transplant Institute, University of Chicago, Chicago, Illinois, USA.
| | - Yolanda Becker
- Transplantation Institute, Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Bertram L Kasiske
- Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA
| | - Bryce A Kiberd
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Alexandre Loupy
- Université Paris Cité, INSERM U970, Paris Institute for Transplantation and Organ Regeneration, F-75015 Paris, France; Department of Kidney Transplantation, Necker Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Jolanta Małyszko
- Department of Nephrology, Dialysis and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Roslyn B Mannon
- Division of Nephrology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Burkhard Tönshoff
- Department of Pediatrics I, University Children's Hospital Heidelberg, Heidelberg, Germany
| | - Michael Cheung
- Kidney Disease: Improving Global Outcomes (KDIGO), Brussels, Belgium
| | - Michel Jadoul
- Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Martin Zeier
- Division of Nephrology, University of Heidelberg, Heidelberg, Germany.
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11
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Budhiraja P, Nguyen M, Heilman R, Kaplan B. The Role of Allograft Nephrectomy in the Failing Kidney Transplant. Transplantation 2023; 107:2486-2496. [PMID: 37122077 DOI: 10.1097/tp.0000000000004625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Patients with failed renal allografts have associated increased morbidity and mortality. The individualization of immunosuppression taper is the key element in managing these patients to avoid graft intolerance and sensitization while balancing the risk of continued immunosuppression. Most patients with uncomplicated chronic allograft failure do not require allograft nephrectomy (AN), and there is no clear evidence that it improves outcomes. The AN procedure is associated with variable morbidity and mortality. It is reserved mainly for early technical graft failure or in symptomatic cases associated with allograft infection, malignancy, or graft intolerance syndrome. It may also be considered in those who cannot tolerate immunosuppression and are at high risk for graft intolerance. AN has been associated with an increased risk of sensitization due to inflammatory response from surgery, immunosuppression withdrawal with allograft failure, and retained endovascular tissue. Although it is presumed that for-cause AN after transplant failure is associated with sensitization, it remains unclear whether elective AN in patients who remain on immunotherapy may prevent sensitization. The current practice of immunosuppression taper has not been shown to prevent sensitization or increase infection risk, but current literature is limited by selection bias and the absence of medication adherence data. We discuss the management of failed allografts based on retransplant candidacy, wait times, risk of graft intolerance syndrome, and immunosuppression side effects. Many unanswered questions remain, and future prospective randomized trials are needed to help guide evidence-based management.
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Affiliation(s)
| | | | | | - Bruce Kaplan
- Department of Medicine, Colorado Center for Transplantation Care, Research and Education (CCTCARE), University of Colorado, Aurora, CO
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Noelle J, Mayet V, Lambert C, Couzi L, Chauveau B, Thierry A, Ecotière L, Bertrand D, Laurent C, Lemal R, Grèze C, Freist M, Heng AE, Rouzaire PO, Garrouste C. Impact of Calcineurin Inhibitor-Based Immunosuppression Maintenance During the Dialysis Period After Kidney Transplant Failure on the Next Kidney Graft Outcome: A Retrospective Multicenter Study With Propensity Score Analysis. Transpl Int 2023; 36:11775. [PMID: 37799669 PMCID: PMC10548547 DOI: 10.3389/ti.2023.11775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 08/25/2023] [Indexed: 10/07/2023]
Abstract
The impact of immunosuppressive therapy (IS) strategies after kidney transplant failure (KTF) on potential future new grafts is poorly established. We assessed the potential benefit of calcineurin inhibitor (CNI)-based IS maintenance throughout the dialysis period on the outcome of the second kidney transplant (KT). We identified 407 patients who underwent a second KT between January 2008 and December 2018 at four French KT centers. Inverse probability of treatment weighting was used to control for potential confounding. We included 205 patients with similar baseline characteristics at KTF: a total of 53 received at least CNIs on the retransplant day (G-CNI), and 152 did not receive any IS (G-STOP). On the retransplant date, G-STOP patients experienced a longer pretransplant dialysis time, were more often hyperimmunized, and underwent more expanded-criteria donor KTs than G-CNI patients. During the second KT follow-up period, rejection episodes were similar in both groups. The 10-year survival rates without death and dialysis were 98.7% and 59.5% in G-CNI and G-STOP patients, respectively. In the multivariable analysis, CNI-based IS maintenance was associated with better survival (hazard ratio: 0.08; 95% confidence interval: 0.01-0.58, p = 0.01). CNI-based IS maintenance throughout the dialysis period after KTF may improve retransplantation outcomes.
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Affiliation(s)
- Juliette Noelle
- Service de Néphrologie Centre hospitalo-universitaire Clermont-Ferrand, Clermont-Ferrand, France
| | - Valentin Mayet
- Service de Néphrologie Centre hospitalo-universitaire Clermont-Ferrand, Clermont-Ferrand, France
| | - Céline Lambert
- Unité de Biostatistiques, Direction de la recherche clinique et d’ innovation, Centre hospitalo-universitaire Clermont-Ferrand, Clermont-Ferrand, France
| | - Lionel Couzi
- Service de Néphrologie, Transplantation, Dialyse et Aphérèses, Centre hospitalo-universitaire Bordeaux, Bordeaux, France
| | - Bertrand Chauveau
- Service de Pathologie, Centre hospitalo-universitaire de Bordeaux, Bordeaux, France
| | - Antoine Thierry
- Service de Néphrologie-Hémodialyse-Transplantation Rénale, Centre hospitalo-universitaire Poitiers, Poitiers, France
| | - Laure Ecotière
- Service de Néphrologie-Hémodialyse-Transplantation Rénale, Centre hospitalo-universitaire Poitiers, Poitiers, France
| | - Dominique Bertrand
- Service de Néphrologie, Centre hospitalier régional universitaire rouen, Rouen, France
| | - Charlotte Laurent
- Service de Néphrologie, Centre hospitalier régional universitaire rouen, Rouen, France
| | - Richard Lemal
- Service d’Histocompatibilité et Immunogénétique, Centre hospitalo-universitaire Clermont-Ferrand, Clermont-Ferrand, France
| | - Clarisse Grèze
- Service de Néphrologie Centre hospitalo-universitaire Clermont-Ferrand, Clermont-Ferrand, France
| | - Marine Freist
- Service de Néphrologie Centre hospitalo-universitaire Clermont-Ferrand, Clermont-Ferrand, France
- Service de Néphrologie et Dialyse, Centre hospitalier Emile Roux, Le Puy-en-Velay, France
| | - Anne-Elisabeth Heng
- Service de Néphrologie Centre hospitalo-universitaire Clermont-Ferrand, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Paul-Olivier Rouzaire
- Service d’Histocompatibilité et Immunogénétique, Centre hospitalo-universitaire Clermont-Ferrand, Clermont-Ferrand, France
- EA 7453 CHELTER, Clermont-Ferrand, France
| | - Cyril Garrouste
- Service de Néphrologie Centre hospitalo-universitaire Clermont-Ferrand, Université Clermont Auvergne, Clermont-Ferrand, France
- EA 7453 CHELTER, Clermont-Ferrand, France
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13
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Alhamad T, Murad H, Dadhania DM, Pavlakis M, Parajuli S, Concepcion BP, Singh N, Murakami N, Casey MJ, Ji M, Lubetzky M, Tantisattamo E, Alomar O, Faravardeh A, Blosser CD, Basu A, Gupta G, Adler JT, Adey D, Woodside KJ, Ong SC, Parsons RF, Lentine KL. The Perspectives of General Nephrologists Toward Transitions of Care and Management of Failing Kidney Transplants. Transpl Int 2023; 36:11172. [PMID: 37456682 PMCID: PMC10348051 DOI: 10.3389/ti.2023.11172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 06/14/2023] [Indexed: 07/18/2023]
Abstract
The management of failing kidney allograft and transition of care to general nephrologists (GN) remain a complex process. The Kidney Pancreas Community of Practice (KPCOP) Failing Allograft Workgroup designed and distributed a survey to GN between May and September 2021. Participants were invited via mail and email invitations. There were 103 respondents with primarily adult nephrology practices, of whom 41% had an academic affiliation. More than 60% reported listing for a second kidney as the most important concern in caring for patients with a failing allograft, followed by immunosuppression management (46%) and risk of mortality (38%), while resistant anemia was considered less of a concern. For the initial approach to immunosuppression reduction, 60% stop antimetabolites first, and 26% defer to the transplant nephrologist. Communicating with transplant centers about immunosuppression cessation was reported to occur always by 60%, and sometimes by 29%, while 12% reported making the decision independently. Nephrologists with academic appointments communicate with transplant providers more than private nephrologists (74% vs. 49%, p = 0.015). There are heterogeneous approaches to the care of patients with a failing allograft. Efforts to strengthen transitions of care and to develop practical practice guidelines are needed to improve the outcomes of this vulnerable population.
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Affiliation(s)
- Tarek Alhamad
- John T. Milliken Department of Medicine, Washington University in St. Louis, Saint Louis, MO, United States
| | - Haris Murad
- John T. Milliken Department of Medicine, Washington University in St. Louis, Saint Louis, MO, United States
| | - Darshana M. Dadhania
- Department of Transplantation Medicine, Weill Cornel Medicine - New York Presbyterian Hospital, New York, NY, United States
| | - Martha Pavlakis
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard University, Boston, MA, United States
| | - Sandesh Parajuli
- Department of Medicine, University of Wisconsin - Madison, Madison, WI, United States
| | | | - Neeraj Singh
- John C. McDonald Regional Transplant Center, Willis Knighton Health System, Shreveport, LA, United States
| | - Naoka Murakami
- Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, United States
| | - Michael J. Casey
- Department of Medicine, Medical University of South Carolina, Charleston, SC, United States
| | - Mengmeng Ji
- John T. Milliken Department of Medicine, Washington University in St. Louis, Saint Louis, MO, United States
| | - Michelle Lubetzky
- Division of Abdominal Transplantation, Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, TX, United States
| | - Ekamol Tantisattamo
- Department of Medicine, University of California, Irvine, Orange, CA, United States
| | - Omar Alomar
- John T. Milliken Department of Medicine, Washington University in St. Louis, Saint Louis, MO, United States
| | - Arman Faravardeh
- SHARP Kidney and Pancreas Transplant Center, San Diego, CA, United States
| | - Christopher D. Blosser
- Department of Medicine, Seattle Children’s Hospital, University of Washington, Seattle, WA, United States
| | - Arpita Basu
- Department of Medicine, Emory University, Atlanta, GA, United States
| | - Gaurav Gupta
- Department of Medicine, Virginia Commonwealth University, Richmond, VA, United States
| | - Joel T. Adler
- Division of Abdominal Transplantation, Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, TX, United States
| | - Deborah Adey
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | | | - Song C. Ong
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Ronald F. Parsons
- Department of Medicine, Emory University, Atlanta, GA, United States
| | - Krista L. Lentine
- Center for Abdominal Transplantation, Saint Louis University, Saint Louis, MO, United States
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14
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Hickey MJ, Singh G, Lum EL. Continuation of immunosuppression vs. immunosuppression weaning in potential repeat kidney transplant candidates: a care management perspective. FRONTIERS IN NEPHROLOGY 2023; 3:1163581. [PMID: 37746029 PMCID: PMC10513023 DOI: 10.3389/fneph.2023.1163581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 05/17/2023] [Indexed: 09/26/2023]
Abstract
Management of immunosuppression in patients with a failing or failed kidney transplant requires a complete assessment of their clinical condition. One of the major considerations in determining immunosuppression is whether or not such an individual is considered a candidate for re-transplantation. Withdrawal of immunosuppression in a re-transplant candidate can result in allosensitization and markedly reduce the chances of a repeat transplant. In this review, we summarize the effects of immunosuppression reduction on HLA sensitization, discuss the impacts of allosensitization in these patients, and explore reduction protocols and future directions. Risks of chronic immunosuppression, medical management of the failing allograft, and the effect of nephrectomy are covered elsewhere in this issue.
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Affiliation(s)
- Michelle J. Hickey
- Department of Pathology and Laboratory Medicine, University of California, Los Angeles (UCLA) Immunogenetics Center, David Geffen School of Medicine, Los Angeles, CA, United States
| | - Gurbir Singh
- Department of Medicine, Division of Nephrology, University of California, Los Angeles (UCLA) David Geffen School of Medicine, Los Angeles, CA, United States
| | - Erik L. Lum
- Department of Medicine, Division of Nephrology, University of California, Los Angeles (UCLA) David Geffen School of Medicine, Los Angeles, CA, United States
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15
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Lentine KL, Amanda M, Xiao H, Wisniewski A, Levan M, Al Ammary F, Sharfuddin A, Axelrod DA, Waterman AD, Kasiske B. Factors enabling transplant program participation in the Scientific Registry of Transplant Recipients (SRTR) Living Donor Collective: A national survey. Clin Transplant 2023; 37:e14908. [PMID: 36622257 PMCID: PMC10423496 DOI: 10.1111/ctr.14908] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 12/24/2022] [Accepted: 01/03/2023] [Indexed: 01/10/2023]
Abstract
BACKGROUND The Scientific Registry of Transplant Recipients (SRTR) Living Donor Collective (LDC), the first effort to create a lifetime registry for living donor candidates in the United States, requires transplant programs to register donor candidates while the SRTR conducts follow-up. METHODS To better understand facilitators and barriers to program participation, we conducted a brief electronic survey of U.S. transplant program staff from October 26, 2021 to December 17, 2021. RESULTS We received 132 responses, with at least one response from 87 living donor programs (46 kidney programs, 33 kidney and liver programs, and eight liver programs alone). We found 86% of program representatives strongly agreed or agreed that funding adequate to cover the cost of data collection would facilitate LDC participation, 92% agreed or strongly agreed with importance of electronic data submission options, and 74% reported that elimination of requirements to submit duplicative pre-operative information to the Organ Procurement and Transplantation Network (OPTN) would be helpful. Other potentially enabling factors include reduction in duration of OPTN postdonation follow-up requirements, ease-of-use, protection from data use for regulation, adequate data security, and equity in data access. CONCLUSION This survey identifies potential targets to strengthen participation in the effort to create a national living donor registry in the United States. Collaboration and investment to overcome barriers to LDC participation among transplant programs are vital to generate long-term data on living donation for donor candidates, donors, and patients in need of transplant.
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Affiliation(s)
- Krista L. Lentine
- Saint Louis University Transplant Center, SSM-Saint Louis Univeristy Hospital, St. Louis, MO
| | | | - Huiling Xiao
- Saint Louis University Transplant Center, SSM-Saint Louis Univeristy Hospital, St. Louis, MO
| | - Addie Wisniewski
- Saint Louis University Transplant Center, SSM-Saint Louis Univeristy Hospital, St. Louis, MO
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16
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Murakami N, Reich AJ, Pavlakis M, Lakin JR. Conservative Kidney Management in Kidney Transplant Populations. Semin Nephrol 2023; 43:151401. [PMID: 37499572 PMCID: PMC10543459 DOI: 10.1016/j.semnephrol.2023.151401] [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] [Indexed: 07/29/2023]
Abstract
Conservative kidney management (CKM) has been increasingly accepted as a therapeutic option for seriously ill patients with advanced chronic kidney disease. CKM is active medical management of advanced chronic kidney disease without dialysis, with a focus on delaying the worsening of kidney disease and minimizing symptom burden. CKM may be considered a suitable option for kidney transplant recipients with poorly functioning and declining allografts, defined as patients with low estimated glomerular filtration rate (<20 mL/min per 1.73 m2) who are approaching allograft failure. CKM may be a fitting option for transplant patients facing high morbidity and mortality with or without dialysis resumption, and it should be offered as a choice for this patient population. In this review, we describe clinical considerations in caring for patients with poorly functioning and declining kidney allografts, especially the unique decision-making process around kidney replacement therapies. We discuss ways to incorporate CKM as an option for these patients. We also discuss financial and policy considerations in providing CKM for this population. Patients with poorly functioning and declining kidney allografts should be supported throughout transitions of care by an interprofessional and multidisciplinary team attuned to their unique challenges. Further research on when, who, and how to integrate CKM into existing care structures for patients with poorly functioning and declining kidney allografts is needed.
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Affiliation(s)
- Naoka Murakami
- Harvard Medical School, Boston, MA; Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA.
| | - Amanda J Reich
- Harvard Medical School, Boston, MA; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA
| | - Martha Pavlakis
- Harvard Medical School, Boston, MA; Beth Israel Deaconess Medical Center, Boston, MA
| | - Joshua R Lakin
- Harvard Medical School, Boston, MA; Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA
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17
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Blosser CD, Portuguese AJ, Santana C, Murakami N. Transplant Onconephrology: An Update. Semin Nephrol 2022; 42:151348. [PMID: 37209580 PMCID: PMC10330527 DOI: 10.1016/j.semnephrol.2023.151348] [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] [Indexed: 05/22/2023]
Abstract
Transplant onconephrology is a growing specialty focused on the health care of kidney transplant recipients with cancer. Given the complexities associated with the care of transplant patients, along with the advent of novel cancer therapies such as immune checkpoint inhibitors and chimeric antigen-receptor T cells, there is a dire need for the subspecialty of transplant onconephrology. The management of cancer in the setting of kidney transplantation is best accomplished by a multidisciplinary team, including transplant nephrologists, oncologists, and patients. This review addresses the current state and future opportunities for transplant onconephrology, including the roles of the multidisciplinary team, and related scientific and clinical knowledge.
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Affiliation(s)
- Christopher D Blosser
- Division of Nephrology, University of Washington, Seattle, WA; Division of Nephrology, Seattle Children's Hospital, Seattle, WA.
| | | | | | - Naoka Murakami
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA.; Harvard Medical School, Boston, MA
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18
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Leal R, Pardinhas C, Martinho A, Sá HO, Figueiredo A, Alves R. Challenges in the Management of the Patient with a Failing Kidney Graft: A Narrative Review. J Clin Med 2022; 11:6108. [PMID: 36294429 PMCID: PMC9605319 DOI: 10.3390/jcm11206108] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 09/29/2022] [Accepted: 09/30/2022] [Indexed: 11/23/2022] Open
Abstract
Patients with a failed kidney allograft have steadily increase in recent years and returning to dialysis after graft loss is one of the most difficult transitions for chronic kidney disease patients and their assistant physicians. The management of these patients is complex and encompasses the treatment of chronic kidney disease complications, dialysis restart and access planning, immunosuppression withdrawal, graft nephrectomy, and evaluation for a potential retransplant. In recent years, several groups have focused on the management of the patient with a failing renal graft and expert recommendations are arising. A review of Pubmed, ScienceDirect and the Cochrane Library was performed focusing on the specific care of these patients, from the management of low clearance complications to concerns with a subsequent kidney transplant. Conclusion: There is a growing interest in the failing renal graft and new approaches to improve these patients' outcomes are being defined including specific multidisciplinary programs, individualized immunosuppression withdrawal schemes, and strategies to prevent HLA sensitization and increase retransplant rates.
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Affiliation(s)
- Rita Leal
- Nephrology Department, Centro Hospitalar e Universitário de Coimbra, 3000-548 Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, 3004-531 Coimbra, Portugal
| | - Clara Pardinhas
- Nephrology Department, Centro Hospitalar e Universitário de Coimbra, 3000-548 Coimbra, Portugal
| | - António Martinho
- Coimbra Histocompatibility Center, Portuguese Institute of Blood and Transplantation, 3041-861 Coimbra, Portugal
| | - Helena Oliveira Sá
- Nephrology Department, Centro Hospitalar e Universitário de Coimbra, 3000-548 Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, 3004-531 Coimbra, Portugal
| | - Arnaldo Figueiredo
- Faculty of Medicine, University of Coimbra, 3004-531 Coimbra, Portugal
- Urology and Kidney Transplantation Unit, Centro Hospitalar e Universitário de Coimbra, 3000-548 Coimbra, Portugal
| | - Rui Alves
- Nephrology Department, Centro Hospitalar e Universitário de Coimbra, 3000-548 Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, 3004-531 Coimbra, Portugal
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19
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Leal R, Pardinhas C, Martinho A, Sá HO, Figueiredo A, Alves R. Strategies to Overcome HLA Sensitization and Improve Access to Retransplantation after Kidney Graft Loss. J Clin Med 2022; 11:5753. [PMID: 36233621 PMCID: PMC9572793 DOI: 10.3390/jcm11195753] [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: 09/10/2022] [Revised: 09/24/2022] [Accepted: 09/26/2022] [Indexed: 12/12/2022] Open
Abstract
An increasing number of patients waitlisted for kidney transplantation have a previously failed graft. Retransplantation provides a significant improvement in morbidity, mortality, and quality of life when compared to dialysis. However, HLA sensitization is a major barrier to kidney retransplantation and the majority of the highly sensitized patients are waiting for a subsequent kidney transplant. A multidisciplinary team that includes immunogeneticists, transplant nephrologists and surgeons, and adequate allocation policies is fundamental to increase access to a kidney retransplant. A review of Pubmed, ScienceDirect, and the Cochrane Library was performed on the challenges of kidney retransplantation after graft loss, focusing on the HLA barrier and new strategies to overcome sensitization. Conclusion: Technical advances in immunogenetics, new desensitization protocols, and complex allocation programs have emerged in recent years to provide a new hope to kidney recipients with a previously failed graft.
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Affiliation(s)
- Rita Leal
- Nephrology Department, Centro Hospitalar e Universitário de Coimbra, 3000-548 Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, 3004-531 Coimbra, Portugal
| | - Clara Pardinhas
- Nephrology Department, Centro Hospitalar e Universitário de Coimbra, 3000-548 Coimbra, Portugal
| | - António Martinho
- Coimbra Histocompatibility Center, Portuguese Institute of Blood and Transplantation, 3041-861 Coimbra, Portugal
| | - Helena Oliveira Sá
- Nephrology Department, Centro Hospitalar e Universitário de Coimbra, 3000-548 Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, 3004-531 Coimbra, Portugal
| | - Arnaldo Figueiredo
- Faculty of Medicine, University of Coimbra, 3004-531 Coimbra, Portugal
- Urology and Kidney Transplantation Unit, Centro Hospitalar e Universitário de Coimbra, 3000-548 Coimbra, Portugal
| | - Rui Alves
- Nephrology Department, Centro Hospitalar e Universitário de Coimbra, 3000-548 Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, 3004-531 Coimbra, Portugal
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20
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Managing the Costs of Routine Follow-up Care After Living Kidney Donation: a Review and Survey of Contemporary Experience, Practices, and Challenges. CURRENT TRANSPLANTATION REPORTS 2022; 9:328-335. [PMID: 36187071 PMCID: PMC9510404 DOI: 10.1007/s40472-022-00379-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2022] [Indexed: 11/12/2022]
Abstract
Purpose of Review While living organ donor follow-up is mandated for 2 years in the USA, formal guidance on recovering associated costs of follow-up care is lacking. In this review, we discuss current billing practices of transplant programs for living kidney donor follow-up, and propose future directions for managing follow-up costs and supporting cost neutrality in donor care. Recent Findings Living donors may incur costs and financial risks in the donation process, including travel, lost time from work, and dependent care. In addition, adherence to the Organ Procurement and Transplantation Network (OPTN) mandate for US transplant programs to submit 6-, 12-, and 24-month postdonation follow-up data to the national registry may incur out-of-pocket medical costs for donors. Notably, the Centers for Medicare and Medicaid Services (CMS) has explicitly disallowed transplant programs to bill routine, mandated follow-up costs to the organ acquisition cost center or to the recipient’s Medicare insurance. We conducted a survey of transplant staff in the USA (distributed October 22, 2020–March 15, 2021), which identified that the mechanisms for recovering or covering the costs of mandated routine postdonation follow-up at responding programs commonly include billing recipients’ private insurance (40%), while 41% bill recipients’ Medicare insurance. Many programs reported utilizing institutional allowancing (up to 50%), and some programs billed the organ acquisition cost center (25%). A small percentage (11%) reported billing donors or donors’ insurance. Summary To maintain a high level of adherence to living donor follow-up without financially burdening donors, up-to-date resources are needed on handling routine donor follow-up costs in ways that are policy-compliant and effective for donors and programs. Development of a government-supported national living donor follow-up registry like the Living Donor Collective may provide solutions for aspects of postdonation follow-up, but requires transplant program commitment to register donors and donor candidates as well as donor engagement with follow-up outreach contacts after donation.
Supplementary Information The online version contains supplementary material available at 10.1007/s40472-022-00379-w.
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21
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Hippen BE, Axelrod DA, Maher K, Li R, Kumar D, Caliskan Y, Alhamad T, Schnitzler M, Lentine KL. Survey of current transplant center practices regarding COVID-19 vaccine mandates in the United States. Am J Transplant 2022; 22:1705-1713. [PMID: 35143100 PMCID: PMC9111251 DOI: 10.1111/ajt.16995] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/04/2022] [Accepted: 02/04/2022] [Indexed: 01/25/2023]
Abstract
An electronic survey canvassing current policies of transplant centers regarding a COVID-19 vaccine mandate for transplant candidates and living donors was distributed to clinicians at US solid organ transplant centers performing transplants from October 14, 2021-November 15, 2021. Responses were received from staff at 141 unique transplant centers. These respondents represented 56.4% of US transplant centers, and responding centers performed 78.5% of kidney transplants and 82.4% of liver transplants in the year prior to survey administration. Only 35.7% of centers reported implementing a vaccine mandate, while 60.7% reported that vaccination was not required. A minority (42%) of responding centers with a vaccine mandate for transplant candidates also mandated vaccination for living organ donors. Centers with a vaccine mandate most frequently cited clinical evidence supporting the efficacy of pre-transplant vaccination (82%) and stewardship obligations to ensure organs were transplanted into the lowest risk patients (64%). Centers without a vaccine mandate cited a variety of reasons including administrative, equity, and legal considerations for their decision. Transplant centers in the United States exhibit significant heterogeneity in COVID-19 vaccination mandate policies for transplant candidates. While all centers encourage vaccination, most centers have not mandated COVID-19 vaccination for candidates and living donors, citing administrative opposition, legal prohibitions, and concern about equity in access to transplants.
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Affiliation(s)
- Benjamin E. Hippen
- Fresenius Medical Care, Charlotte, North Carolina,Correspondence Benjamin E. Hippen, 729 East Worthington Avenue, Charlotte, NC 28203, USA.
| | | | - Kennan Maher
- Saint Louis University Transplant Center, St. Louis, Missouri
| | - Ruixin Li
- Saint Louis University Transplant Center, St. Louis, Missouri
| | | | - Yasar Caliskan
- Saint Louis University Transplant Center, St. Louis, Missouri
| | | | - Mark Schnitzler
- Saint Louis University Transplant Center, St. Louis, Missouri
| | - Krista L. Lentine
- Saint Louis University Transplant Center, St. Louis, Missouri,Krista L. Lentine, Saint Louis University Transplant Center, 1201 S. Grand Blvd., St. Louis, MO, 63104, USA.
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22
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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.
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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
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23
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Garg N, Viney K, Burger J, Hidalgo L, Parajuli S, Aziz F, Mohamed MA, Djamali A, Mandelbrot DA. Factors affecting sensitization following kidney allograft failure. Clin Transplant 2022; 36:e14558. [PMID: 34923658 DOI: 10.1111/ctr.14558] [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: 05/25/2021] [Revised: 12/03/2021] [Accepted: 12/07/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Management of immunosuppression in a kidney transplant recipient with a failed allograft is complex; continuation carries infectious and metabolic risks, and discontinuation can lead to sensitization. METHODS We evaluated risk factors for sensitization in 89 kidney or simultaneous kidney-pancreas recipients, whose kidney transplant failed after January, 2013 and who were subsequently re-evaluated for kidney transplantation. RESULTS Among recipients with pre graft failure cPRA < 50%, calcineurin inhibitor (CNI) continuation (OR .11, P = .003) and steroid continuation (OR .17, P = .04) were associated with significantly lower odds of developing an absolute increase in cPRA of ≥50%. Each additional HLA mismatch was associated with OR of 2.16 (P = .02). CNI use was associated with OR of .09 (P = .001) for increase in cPRA to ≥80% if pre graft failure cPRA was <50%, and OR of .08 (P = .02) for increase in cPRA to ≥98% if pre graft cPRA was <80%. Anti-metabolites were continued more often among recipients who had a <50% increase (P = .006); however, the association was lost on multivariate analyses. Weaning off immunosuppression and higher number of HLA mismatches are associated with greater likelihood of sensitization. CONCLUSION While both CNI and steroid continuation conferred some protection against increase in cPRA, CNI continuation was the only factor protecting against becoming highly sensitized.
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Affiliation(s)
- Neetika Garg
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Kelley Viney
- HLA Laboratory, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - John Burger
- HLA Laboratory, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Luis Hidalgo
- HLA Laboratory, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Sandesh Parajuli
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Fahad Aziz
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Maha A Mohamed
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Arjang Djamali
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Division of Transplant Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Didier A Mandelbrot
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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24
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Lentine KL, Fleetwood VA, Caliskan Y, Randall H, Wellen JR, Lichtenberger M, Dedert C, Rothweiler R, Marklin G, Brockmeier D, Schnitzler MA, Husain SA, Mohan S, Kasiske BL, Cooper M, Mannon RB, Axelrod DA. Deceased Donor Procurement Biopsy Practices, Interpretation, and Histology-Based Decision Making: A Survey of U.S. Transplant Centers. Kidney Int Rep 2022; 7:1268-1277. [PMID: 35685316 PMCID: PMC9171615 DOI: 10.1016/j.ekir.2022.03.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/13/2022] [Accepted: 03/21/2022] [Indexed: 10/31/2022] Open
Abstract
Introduction Methods Results Conclusion
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25
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Doshi MD, Singh N, Hippen BE, Woodside KJ, Mohan P, Byford HL, Cooper M, Dadhania DM, Ainapurapu S, Lentine KL. Transplant Clinician Opinions on Use of Race in the Estimation of Glomerular Filtration Rate. Clin J Am Soc Nephrol 2021; 16:1552-1559. [PMID: 34620650 PMCID: PMC8499001 DOI: 10.2215/cjn.05490421] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 08/13/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Current race-based eGFR calculators assign a higher eGFR value to Black patients, which could affect the care of kidney transplant candidates and potential living donors. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a survey of staff at adult kidney transplant centers in the United States (December 17, 2020 to February 28, 2021) to assess opinions on use of race-based eGFR equations for waitlisting and living donor candidate evaluation, availability of serum cystatin C testing and measured GFR, and related practices. RESULTS Respondents represented 57% (124 of 218) of adult kidney transplant programs, and the responding centers conducted 70% of recent kidney transplant volume. Most (93%) programs use serum creatinine-based eGFR for listing candidates. However, only 6% of respondents felt that current race-based eGFR calculators are appropriate, with desire for change grounded in concerns for promotion of health care disparities by current equations and inaccuracies in reporting of race. Most respondents (70%) believed that elimination of race would allow more preemptive waitlisting for Black patients, but a majority (79%) also raised concerns that such an approach could incur harms. More than one third of the responding programs lacked or were unsure of availability of testing for cystatin C or measured GFR. At this time, 40% of represented centers did not plan to remove race from eGFR calculators, 46% were planning to remove, and 15% had already done so. There was substantial variability in eGFR reporting and listing of multiracial patients with some Black ancestry. There was no difference in GFR acceptance thresholds for Black versus non-Black living donors. CONCLUSIONS This national survey highlights a broad consensus that extant approaches to GFR estimation are unsatisfactory, but it also identified a range of current opinions.
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Affiliation(s)
| | - Neeraj Singh
- Willis Knighton Health System, Shreveport, Louisiana
| | | | | | - Prince Mohan
- Geisinger Medical Center, Danville, Pennsylvania
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26
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Lentine KL, Pastan S, Mohan S, Reese PP, Leichtman A, Delmonico FL, Danovitch GM, Larsen CP, Harshman L, Wiseman A, Kramer HJ, Vassalotti J, Joseph J, Longino K, Cooper M, Axelrod DA. A Roadmap for Innovation to Advance Transplant Access and Outcomes: A Position Statement From the National Kidney Foundation. Am J Kidney Dis 2021; 78:319-332. [PMID: 34330526 DOI: 10.1053/j.ajkd.2021.05.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 05/01/2021] [Indexed: 02/07/2023]
Abstract
Over the past 65 years, kidney transplantation has evolved into the optimal treatment for patients with kidney failure, dramatically reducing suffering through improved survival and quality of life. However, access to transplant is still limited by organ supply, opportunities for transplant are inequitably distributed, and lifelong transplant survival remains elusive. To address these persistent needs, the National Kidney Foundation convened an expert panel to define an agenda for future research. The key priorities identified by the panel center on the needs to develop and evaluate strategies to expand living donation, improve waitlist management and transplant readiness, maximize use of available deceased donor organs, and extend allograft longevity. Strategies targeting the critical goal of decreasing organ discard that warrant research investment include educating patients and clinicians about potential benefits of accepting nonstandard organs, use of novel organ assessment technologies and real-time decision support, and approaches to preserve and resuscitate allografts before implantation. The development of personalized strategies to reduce the burden of lifelong immunosuppression and support "one transplant for life" was also identified as a vital priority. The panel noted the specific goal of improving transplant access and graft survival for children with kidney failure. This ambitious agenda will focus research investment to promote greater equity and efficiency in access to transplantation, and help sustain long-term benefits of the gift of life for more patients in need.
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Affiliation(s)
- Krista L Lentine
- Saint Louis University Center for Abdominal Transplantation, St Louis, MO.
| | - Stephen Pastan
- Department of Medicine, Emory Transplant Center, Atlanta, GA
| | - Sumit Mohan
- Department of Medicine, Columbia University Medical Center, New York, NY
| | - Peter P Reese
- Renal-Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia, PA
| | - Alan Leichtman
- Department of Medicine, University of Michigan, Ann Arbor, MI
| | | | | | | | - Lyndsay Harshman
- Department of Pediatrics, University of Iowa Transplant Institute, Iowa City, IA
| | - Alexander Wiseman
- Department of Medicine, Centura Health-Porter Adventist Hospital, Aurora, CO
| | | | - Joseph Vassalotti
- National Kidney Foundation, New York, NY; Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | | | - Matthew Cooper
- Department of Surgery, Medstar Georgetown Transplant Institute, Washington, DC
| | - David A Axelrod
- Department of Surgery, University of Iowa Transplant Institute, Iowa City, IA
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