1
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Kumar A, Bonnell L, Kuppachi S. Early Pre-Emptive Kidney Transplant Does Not Offer Any Mortality Benefits: A Study of Trends in Pre-Emptive Kidney Transplantation Over the Last Two Decades. Transplant Proc 2025; 57:538-543. [PMID: 40140312 DOI: 10.1016/j.transproceed.2025.02.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2024] [Accepted: 02/26/2025] [Indexed: 03/28/2025]
Abstract
BACKGROUND Pre-emptive kidney transplantation is considered the optimal treatment for end stage kidney disease (ESKD). The aim of the study is to evaluate current state of pre-emptive kidney transplants in the United States with focus on mortality benefit with early pre-emptive transplants. METHODS Using the United Network of Organ Sharing database, we explored trends in pre-emptive kidney transplantation in first time adult recipients. We created four groups (estimated glomerular filtration rate [eGFR] < 10 mL/min/1.73 m2, 10 to < 15 mL/min/1.73 m2, 15 to < 20 mL/min/1.73 m2, and ≥ 20 mL/min/1.73 m2) based on the eGFR at the time of transplant. Multivariable Cox regression was used to assess the difference in mortality and cumulative incidence competing risk (CICR) method was used to compare risk of ESKD among the groups. RESULTS Pre-emptive kidney transplant remain at roughly 18% of total kidney transplant (33% were from deceased donors and 67% from living donors). White patients with a higher level of education and with private insurance were most likely to receive pre-emptive kidney transplant. No difference in mortality was found in the four eGFR groups. In a subgroup analysis looking only at recipients of pre-emptive kidney transplant from living donors, no mortality difference was again noted among the four groups. CONCLUSIONS Pre-emptive kidney transplants continue to favor a select population and remain at low numbers (9% of total deceased donor kidney transplants and 33% of living donor kidney transplants [LDKTs]). Early pre-emptive living donor kidney transplant did not confer a mortality benefit compared to transplantation when eGFR was < 15 mL/min/1.73 m2.
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Affiliation(s)
- Abhishek Kumar
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.
| | - Levi Bonnell
- Department of General Internal Medicine, University of Vermont, Burlington, Vermont
| | - Sarat Kuppachi
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa
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2
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Kramer A, Boenink R, Mercado Vergara CG, Bell S, Kerschbaum J, Rodríguez Arévalo OL, Mazuecos A, de Vries APJ, Reisæter AV, Wong EHS, Lundgren T, Valentin MO, Ordoñez Alvarez FA, Melilli E, Finne P, Segelmark M, Couchoud C, Sørensen SS, Ferraro PM, Arnol M, Arici M, Ortiz A, Jager KJ, Abramowicz D, Stel VS, Hellemans R. Time trends in preemptive kidney transplantation in Europe: an ERA registry study. Nephrol Dial Transplant 2024; 39:2100-2112. [PMID: 38724446 PMCID: PMC11648960 DOI: 10.1093/ndt/gfae105] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Indexed: 11/28/2024] Open
Abstract
BACKGROUND Preemptive kidney transplantation (PEKT) has better outcomes when compared with transplantation after dialysis. We aimed to examine trends in PEKT between 2000 and 2019 in Europe and to provide an overview of associated policies, barriers and initiatives. METHODS Adult patients from 12 European countries who received a preemptive kidney transplant were included. The representatives of the registries providing these data were questioned on the policies, barriers and initiatives around PEKT. RESULTS Between 2000 and 2019, 20 251 adults underwent PEKT [11 169 from living donors (LDs), 8937 from deceased donors (DDs)]. The proportion of first kidney transplantations that were preemptive more than doubled from 7% in 2000 to 18% in 2019, reflecting a similar relative increase for LD kidney recipients (from 21% to 43%) and DD kidney recipients (from 4% to 11%). Large international differences were found. The increase in PEKT was observed across all age, sex and primary renal disease groups. Countries had similar criteria for preemptive waitlisting. Barriers mentioned included donor shortage, late referral to the transplant center and long donoror recipient work-up. Suggested initiatives included raising awareness on the possibility of PEKT, earlier start and shorter work-up time for recipient and LD. CONCLUSIONS Over the last two decades the proportion of patients receiving a first kidney transplant preemptively has more than doubled, reflecting a similar relative increase for living and DD kidney recipients.
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Affiliation(s)
- Anneke Kramer
- ERA Registry, Amsterdam UMC location University of Amsterdam, Department of Medical Informatics, Amsterdam, The Netherlands
- Amsterdam Public Health, Quality of Care and Ageing & Later Life, Amsterdam, The Netherlands
| | - Rianne Boenink
- ERA Registry, Amsterdam UMC location University of Amsterdam, Department of Medical Informatics, Amsterdam, The Netherlands
- Amsterdam Public Health, Quality of Care and Ageing & Later Life, Amsterdam, The Netherlands
| | - Cynthia G Mercado Vergara
- Amsterdam UMC location University of Amsterdam, Department of Medical Informatics, Amsterdam, The Netherlands
| | - Samira Bell
- Scottish Renal Registry, Public Health Scotland, Meridian Court, Glasgow, UK
- Division of Population Health and Genomics, University of Dundee, Dundee, UK
| | - Julia Kerschbaum
- Austrian Dialysis and Transplant Registry, Department of Internal Medicine IV – Nephrology and Hypertension, Medical University Innsbruck, Innsbruck, Austria
| | - Olga L Rodríguez Arévalo
- Registry of Renal Patients of the Valencian Community, General Directorate of Public Health and Addictions, Ministry of Universal Health and Public Health, Valencia, Spain
- Health and Well-being Technologies Program, Polytechnic University of Valencia, Valencia, Spain
| | | | - Aiko P J de Vries
- Department of Medicine, Division of Nephrology, Leiden Transplant Center, Leiden University Medical Center, Leiden, The Netherlands
| | - Anna V Reisæter
- Department of Transplantation Medicine, Oslo University hospital, Rikshospitalet, Norway
| | - Esther H S Wong
- UK Kidney Association, UK Renal Registry, University of Bristol, Bristol, UK
| | - Torbjörn Lundgren
- Department of Transplantation Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - María O Valentin
- Nephrology Department, Valdecilla Hospital, University of Cantabria, IDIVAL, Santander, Spain
| | | | - Edoardo Melilli
- Department of Nephrology, Hospital Universitari de Bellvitge (HUB), Barcelona, Spain
| | - Patrik Finne
- Abdominal Center Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mårten Segelmark
- Department of Clinical Sciences, Lund University and Department of Endocrinology, Nephrology and Rheumatology, Skane University Hospital, Lund, Sweden
| | - Cécile Couchoud
- REIN Registry, Agence de la biomédecine, Saint-Denis La Plaine, France
| | - Søren S Sørensen
- Department of Nephrology P, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Pietro Manuel Ferraro
- Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC Nefrologia, Rome, Italy
- Università Cattolica del Sacro Cuore, Sede di Roma, Largo A. Gemelli 8, Roma, Italy
| | - Miha Arnol
- Department of Nephrology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Mustafa Arici
- Department of Nephrology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Alberto Ortiz
- Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Fundación Renal Iñigo Alvarez de Toledo, Madrid, Spain
| | - Kitty J Jager
- ERA Registry, Amsterdam UMC location University of Amsterdam, Department of Medical Informatics, Amsterdam, The Netherlands
- Amsterdam Public Health, Quality of Care and Ageing & Later Life, Amsterdam, The Netherlands
| | - Daniel Abramowicz
- Department of Nephrology/Hypertension, Antwerp, University Hospital, Edegem, Belgium
- Laboratory of Experimental Medicine and Pediatrics, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Vianda S Stel
- ERA Registry, Amsterdam UMC location University of Amsterdam, Department of Medical Informatics, Amsterdam, The Netherlands
- Amsterdam Public Health, Quality of Care and Ageing & Later Life, Amsterdam, The Netherlands
| | - Rachel Hellemans
- Department of Nephrology/Hypertension, Antwerp, University Hospital, Edegem, Belgium
- Laboratory of Experimental Medicine and Pediatrics, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
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3
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Maclay LM, Yu M, Amaral S, Adler JT, Sandoval PR, Ratner LE, Schold JD, Mohan S, Husain SA. Disparities in Access to Timely Waitlisting Among Pediatric Kidney Transplant Candidates. Pediatrics 2024; 154:e2024065934. [PMID: 39086359 PMCID: PMC11350102 DOI: 10.1542/peds.2024-065934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 05/06/2024] [Accepted: 05/08/2024] [Indexed: 08/02/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Kidney transplantation with minimal or no dialysis exposure provides optimal outcomes for children with end-stage kidney disease. We sought to understand disparities in timely access to transplant waitlisting. METHODS We conducted a retrospective, registry-based cohort study of candidates ages 3 to 17 added to the US kidney transplant waitlist 2015 to 2019. We defined "preemptive waitlisting" as waitlist addition before receiving dialysis and compared demographics of candidates based on preemptive status. We used competing risk regression to determine the association between preemptive waitlisting and transplantation. We then identified waitlist additions age >18 who initiated dialysis as children, thereby missing pediatric allocation prioritization, and evaluated the association between waitlisting with pediatric prioritization and transplantation. RESULTS Among 4506 pediatric candidates, 48% were waitlisted preemptively. Female sex, Hispanic ethnicity, Black race, and public insurance were associated with lower adjusted relative risk of preemptive waitlisting. Preemptive listing was not associated with time from waitlist activation to transplantation (adjusted hazard ratio 0.94, 95% confidence interval 0.87-1.02). Among transplant recipients waitlisted preemptively, 68% had no pretransplant dialysis, whereas recipients listed nonpreemptively had median 1.6 years of dialysis at transplant. Among 415 candidates initiating dialysis as children but waitlisted as adults, transplant rate was lower versus nonpreemptive pediatric candidates after waitlist activation (adjusted hazard ratio 0.54, 95% confidence interval 0.44-0.66). CONCLUSIONS Disparities in timely waitlisting are associated with differences in pretransplant dialysis exposure despite no difference in time to transplant after waitlist activation. Young adults who experience delays may miss pediatric prioritization, highlighting an area for policy intervention.
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Affiliation(s)
- Lindsey M. Maclay
- Departments of Medicine, Division of Nephrology
- Columbia University Renal Epidemiology Group, New York, New York
| | - Miko Yu
- Departments of Medicine, Division of Nephrology
- Columbia University Renal Epidemiology Group, New York, New York
| | - Sandra Amaral
- Division of Nephrology, Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joel T. Adler
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, Texas
| | - P. Rodrigo Sandoval
- Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Lloyd E. Ratner
- Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Jesse D. Schold
- Department of Surgery, University of Colorado – Anschutz Medical Campus, Aurora
- Department of Epidemiology, School of Public Health, University of Colorado – Anschutz Medical Campus, Aurora
| | - Sumit Mohan
- Departments of Medicine, Division of Nephrology
- Columbia University Renal Epidemiology Group, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Syed Ali Husain
- Departments of Medicine, Division of Nephrology
- Columbia University Renal Epidemiology Group, New York, New York
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Gadelkareem RA, Abdelgawad AM, Reda A, Azoz NM, Zarzour MA, Mohammed N, Hammouda HM, Khalil M. Preemptive living donor kidney transplantation: Access, fate, and review of the status in Egypt. World J Nephrol 2023; 12:40-55. [PMID: 37476008 PMCID: PMC10354566 DOI: 10.5527/wjn.v12.i3.40] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 02/22/2023] [Accepted: 03/14/2023] [Indexed: 05/19/2023] Open
Abstract
BACKGROUND Preemptive living donor kidney transplantation (PLDKT) is recommended as the optimal treatment for end-stage renal disease. AIM To assess the rate of PLDKT among patients who accessed KT in our center and review the status of PLDKT in Egypt. METHODS We performed a retrospective review of the patients who accessed KT in our center from November 2015 to November 2022. In addition, the PLDKT status in Egypt was reviewed relative to the literature. RESULTS Of the 304 patients who accessed KT, 32 patients (10.5%) had preemptive access to KT (PAKT). The means of age and estimated glomerular filtration rate were 31.7 ± 13 years and 12.8 ± 3.5 mL/min/1.73 m2, respectively. Fifty-nine patients had KT, including 3 PLDKTs only (5.1% of total KTs and 9.4% of PAKT). Twenty-nine patients (90.6%) failed to receive PLDKT due to donor unavailability (25%), exclusion (28.6%), regression from donation (3.6%), and patient regression on starting dialysis (39.3%). In multivariate analysis, known primary kidney disease (P = 0.002), patient age (P = 0.031) and sex (P = 0.001) were independent predictors of achievement of KT in our center. However, PAKT was not significantly (P = 0.065) associated with the achievement of KT. Review of the literature revealed lower rates of PLDKT in Egypt than those in the literature. CONCLUSION Patient age, sex, and primary kidney disease are independent predictors of achieving living donor KT. Despite its non-significant effect, PAKT may enhance the low rates of PLDKT. The main causes of non-achievement of PLDKT were patient regression on starting regular dialysis and donor unavailability or exclusion.
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Affiliation(s)
- Rabea Ahmed Gadelkareem
- Department of Urology, Assiut Urology and Nephrology Hospital, Faculty of Medicine, Assiut University, Assiut 71515, Egypt
| | - Amr Mostafa Abdelgawad
- Department of Urology, Assiut Urology and Nephrology Hospital, Faculty of Medicine, Assiut University, Assiut 71515, Egypt
| | - Ahmed Reda
- Department of Urology, Assiut Urology and Nephrology Hospital, Faculty of Medicine, Assiut University, Assiut 71515, Egypt
| | - Nashwa Mostafa Azoz
- Department of Internal Medicine, Assiut University Hospital, Faculty of Medicine, Assiut University, Assiut 71515, Egypt
| | - Mohammed Ali Zarzour
- Department of Urology, Assiut Urology and Nephrology Hospital, Faculty of Medicine, Assiut University, Assiut 71515, Egypt
| | - Nasreldin Mohammed
- Department of Urology, Assiut Urology and Nephrology Hospital, Faculty of Medicine, Assiut University, Assiut 71515, Egypt
| | - Hisham Mokhtar Hammouda
- Department of Urology, Assiut Urology and Nephrology Hospital, Faculty of Medicine, Assiut University, Assiut 71515, Egypt
| | - Mahmoud Khalil
- Department of Urology, Assiut Urology and Nephrology Hospital, Faculty of Medicine, Assiut University, Assiut 71515, Egypt
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5
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Smith J, Harris OO, Adey D, Park M. Barriers and facilitators to the transplant process among patients living with polycystic kidney disease: a qualitative Approach. BMC Nephrol 2023; 24:119. [PMID: 37127564 PMCID: PMC10150665 DOI: 10.1186/s12882-023-03174-6] [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: 08/26/2022] [Accepted: 04/18/2023] [Indexed: 05/03/2023] Open
Abstract
BACKGROUND Kidney transplant is the gold standard for renal replacement therapy in patients with autosomal dominant polycystic kidney disease (ADPKD), which is the fourth leading cause of kidney failure. Despite the medical and economic benefits of preemptive kidney transplant over dialysis before transplant, only 9-21% of qualifying patients receive preemptive transplants. Given the low rates of preemptive transplant, the aim of this study was to determine perceived facilitators and barriers to preemptive transplant among ADPKD patients using a qualitative approach. METHODS Data were collected between July 2021 and January 2022 from virtual individual semi-structured interviews of 16 adult participants with ADPKD. Qualitative analysis of the recorded interviews was conducted to generate themes. RESULTS Our findings revealed two themes specific for facilitators to preemptive transplant (social support and patient agency) and three themes specific to barriers for preemptive transplant (inadequate social support, gaps in knowledge, and institutional and systemic policies). The results also include various subthemes and the application of these themes to the social ecological model. CONCLUSIONS These findings suggest that increasing social support and patient agency, such as through patient navigator programs and encouraging effective communication between health care providers and patients, can facilitate the transplant process. Increasing dissemination of transplant knowledge from institutions and systems to patients through paired kidney exchange education and live donor outreach can also increase timely access to preemptive kidney transplants for patients with ADPKD. Our findings are limited by our single site study in the US, which may not apply to individuals experiencing different social, cultural, and health access conditions.
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Affiliation(s)
- Juliana Smith
- University of California, San Francisco School of Medicine, 505 Parnassus Ave, San Francisco, CA, 94143, United States
| | - Orlando O Harris
- Department of Community Health Systems, School of Nursing, University of California, San Francisco 2 Koret Way, N 531E, Box 0608, San Francisco, CA, 94143, United States
| | - Deborah Adey
- Department of Medicine, Division of Nephrology, University of California, San Francisco, 400 Parnassus, ACC Box 701 KTU, Box 0532, San Francisco, CA, 94143, United States
| | - Meyeon Park
- Department of Medicine, Division of Nephrology, University of California, San Francisco, 400 Parnassus, ACC Box 701 KTU, Box 0532, San Francisco, CA, 94143, United States.
- , 500 Parnassus Ave MUW 418, Box 0532, San Francisco, CA, 94143, United States.
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6
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Dayal C, Davies M, Diana NE, Meyers A. Living kidney donation in a developing country. PLoS One 2022; 17:e0268183. [PMID: 35536829 PMCID: PMC9089923 DOI: 10.1371/journal.pone.0268183] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 04/24/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Living kidney donation has been advocated as a means to ameliorate the chronic shortage of organs for transplantation. Significant rates of comorbidity and familial risk for kidney disease may limit this approach in the local context; there is currently limited data describing living donation in Africa. METHODS We assessed reasons for non-donation and outcomes following donation in a cohort of 1208 ethnically diverse potential living donors evaluated over a 32-year period at a single transplant centre in South Africa. RESULTS Medical contraindications were the commonest reason for donor exclusion. Black donors were more frequently excluded (52.1% vs. 39.3%; p<0.001), particularly for medical contraindications (44% vs. 35%; p<0.001); 298 donors proceeded to donor nephrectomy (24.7%). Although no donor required kidney replacement therapy, an estimated glomerular filtration rate below 60 ml/min/1.73 m2 was recorded in 27% of donors at a median follow-up of 3.7 years, new onset albuminuria >300 mg/day was observed in 4%, and 12.8% developed new-onset hypertension. Black ethnicity was not associated with an increased risk of adverse post-donation outcomes. CONCLUSION This study highlights the difficulties of pursuing live donation in a population with significant medical comorbidity, but provides reassurance of the safety of the procedure in carefully selected donors in the developing world.
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Affiliation(s)
- Chandni Dayal
- Division of Nephrology, Department of Internal Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Malcolm Davies
- Division of Nephrology, Department of Internal Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Nina Elisabeth Diana
- Division of Nephrology, Department of Internal Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Anthony Meyers
- Division of Nephrology, Department of Internal Medicine, University of the Witwatersrand, Johannesburg, South Africa
- National Kidney Foundation, Johannesburg, South Africa
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7
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Preemptive simultaneous pancreas kidney transplantation has survival benefit to patient. Kidney Int 2022; 102:421-430. [DOI: 10.1016/j.kint.2022.04.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 03/07/2022] [Accepted: 04/08/2022] [Indexed: 11/18/2022]
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8
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Early Referral, Living Donation, and Preemptive Kidney Transplant. Transplant Proc 2022; 54:615-621. [PMID: 35246327 DOI: 10.1016/j.transproceed.2021.11.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 10/16/2021] [Accepted: 11/18/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Preemptive kidney transplant (PKT) is recognized as the most beneficial and cost-effective form of renal replacement therapy among patients with end-stage renal disease. Despite optimal outcomes and improved quality of life associated with PKT, its use as a first renal replacement therapy remains low among patients with end-stage renal disease. The goal of this retrospective cohort study was to compare, among adult kidney transplant recipients, characteristics across PKT status. METHODS We compared the characteristics of patients who did and did not have a PKT over 5 years, from 2010 to 2014, using the electronic health records of Kaiser Permanente Mid-Atlantic States. RESULTS A total of 233 patients received a kidney-alone transplant, and, of these, 44 patients (19%) were PKT and 189 patients (81%) were non-PKT. Of the patients in the PKT group, 43% received a kidney from a deceased donor. PKT recipients were more often White, had polycystic kidney disease or glomerulonephritis, received a living donor organ, and were transplanted at certain transplant centers. Estimated glomerular filtration rate on listing for those who received a deceased donor transplant was higher in PKT than non-PKT patients listed pre-dialysis. CONCLUSIONS PKT was associated with having a living kidney donor and with having a higher estimated glomerular filtration rate at listing for deceased donor recipients.
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9
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Abstract
Cardiovascular disease remains a leading cause of death and morbidity in kidney transplant recipients and a common reason for post-transplant hospitalization. Several traditional and nontraditional cardiovascular risk factors exist, and many of them present pretransplant and worsened, in part, due to the addition of immunosuppression post-transplant. We discuss optimal strategies for identification and treatment of these risk factors, including the emerging role of sodium-glucose cotransporter 2 inhibitors in post-transplant diabetes and cardiovascular disease. We present common types of cardiovascular disease observed after kidney transplant, including coronary artery disease, heart failure, pulmonary hypertension, arrhythmia, and valvular disease. We also discuss screening, treatment, and prevention of post-transplant cardiac disease. We highlight areas of future research, including the need for goals and best medications for risk factors, the role of biomarkers, and the role of screening and intervention.
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Affiliation(s)
- Kelly A. Birdwell
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Meyeon Park
- Division of Nephrology, Department of Medicine, University of California, San Francisco, California
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10
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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.
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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
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11
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Lenihan CR, Liu S, Airy M, Walther C, Montez-Rath ME, Winkelmayer WC. The Association of Pre-Kidney Transplant Dialysis Modality with de novo Posttransplant Heart Failure. Cardiorenal Med 2021; 11:209-217. [PMID: 34515084 DOI: 10.1159/000518535] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 06/25/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Heart failure (HF) after kidney transplantation is a significant but understudied problem. Pretransplant dialysis modality could influence incident HF risk through differing cardiac stressors. However, whether pretransplant dialysis modality is associated with the development of posttransplant HF is unknown. METHODS We used the US Renal Data System to assemble a cohort of 27,701 patients who underwent their first kidney transplant in the USA between the years 2005 and 2012 and who had Medicare fee-for-service coverage for >6 months preceding their transplant date. Patients with any HF diagnosis prior to transplant were excluded. Detailed baseline patient characteristics and comorbidities were abstracted. The outcome of interest was de novo posttransplant HF. Pretransplant dialysis modality was defined as the dialysis modality used at the time of transplant. We conducted time-to-event analyses using Cox regression. Death was treated as a competing risk in the study's primary analysis. Graft failure was included as a time-varying covariate. RESULTS Among eligible patients, 81% were treated with hemodialysis prior to transplant, and hemodialysis patients were more likely to be male, had a shorter dialysis vintage, and had more diabetes and vascular disease diagnoses. When adjusted for all available demographic and clinical data, pretransplant treatment with hemodialysis (vs. peritoneal dialysis) was associated with a 19% increased risk in de novo posttransplant HF, with sub-distribution HR 1.19 (95% CI: 1.09-1.29). CONCLUSIONS Our results suggest that choice of pretransplant dialysis modality may impact the development of posttransplant HF.
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Affiliation(s)
- Colin R Lenihan
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Sai Liu
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Medha Airy
- Selzman Institute for Kidney Health, Section of Nephrology, Baylor College of Medicine, Houston, Texas, USA
| | - Carl Walther
- Selzman Institute for Kidney Health, Section of Nephrology, Baylor College of Medicine, Houston, Texas, USA
| | - Maria E Montez-Rath
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Baylor College of Medicine, Houston, Texas, USA
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12
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van Dellen D, Burnapp L, Citterio F, Mamode N, Moorlock G, van Assche K, Zuidema WC, Lennerling A, Dor FJMF. Pre-emptive live donor kidney transplantation-moving barriers to opportunities: An ethical, legal and psychological aspects of organ transplantation view. World J Transplant 2021; 11:88-98. [PMID: 33954087 PMCID: PMC8058646 DOI: 10.5500/wjt.v11.i4.88] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 01/30/2021] [Accepted: 03/12/2021] [Indexed: 02/06/2023] Open
Abstract
Live donor kidney transplantation (LDKT) is the optimal treatment modality for end stage renal disease (ESRD), enhancing patient and graft survival. Pre-emptive LDKT, prior to requirement for renal replacement therapy (RRT), provides further advantages, due to uraemia and dialysis avoidance. There are a number of potential barriers and opportunities to promoting pre-emptive LDKT. Significant infrastructure is needed to deliver robust programmes, which varies based on socio-economic standards. National frameworks can impact on national prioritisation of pre-emptive LDKT and supporting education programmes. Focus on other programme’s components, including deceased kidney transplantation and RRT, can also hamper uptake. LDKT programmes are designed to provide maximal benefit to the recipient, which is specifically true for pre-emptive transplantation. Health care providers need to be educated to maximize early LDKT referral. Equitable access for varying population groups, without socio-economic bias, also requires prioritisation. Cultural barriers, including religious influence, also need consideration in developing successful outcomes. In addition, the benefit of pre-emptive LDKT needs to be emphasised, and opportunities provided to potential donors, to ensure timely and safe work-up processes. Recipient education and preparation for pre-emptive LDKT needs to ensure increased uptake. Awareness of the benefits of pre-emptive transplantation require prioritisation for this population group. We recommend an approach where patients approaching ESRD are referred early to pre-transplant clinics facilitating early discussion regarding pre-emptive LDKT and potential donors for LDKT are prioritized for work-up to ensure success. Education regarding pre-emptive LDKT should be the norm for patients approaching ESRD, appropriate for the patient’s cultural needs and physical status. Pre-emptive transplantation maximize benefit to potential recipients, with the potential to occur within successful service delivery. To fully embrace preemptive transplantation as the norm, investment in infrastructure, increased awareness, and donor and recipient support is required.
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Affiliation(s)
- David van Dellen
- Department of Renal and Pancreas Transplantation, Manchester University NHS Foundation Trust, Manchester M13 9WL, United Kingdom
- Department of Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, United Kingdom
| | - Lisa Burnapp
- Department of Transplantation, Guy's and St. Thomas' NHS Foundation Trust, London SE1 9RT, United Kingdom
| | - Franco Citterio
- Department of Surgery, Renal Transplantation, Catholic University, Rome 00153, Italy
| | - Nizam Mamode
- Department of Transplantation, Guy's and St. Thomas' NHS Foundation Trust, London SE1 9RT, United Kingdom
| | - Greg Moorlock
- Warwick Medical School, University of Warwick, Coventry CV4 7AL, United Kingdom
| | - Kristof van Assche
- Res Grp Personal Rights & Property Rights, University of Antwerp, Antwerp 2000, Belgium
| | - Willij C Zuidema
- Departments of Internal Medicine, Erasmus Medical Centre, Rotterdam CE 1015, Netherlands
| | - Annette Lennerling
- The Transplant Centre, Sahlgrenska University Hospital, Gothenburg S-413 45, Sweden
- Institute of Health and Care Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg S-405 30, Sweden
| | - Frank JMF Dor
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, London W2 1NY, United Kingdom
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King KL, Husain SA, Jin Z, Brennan C, Mohan S. Trends in Disparities in Preemptive Kidney Transplantation in the United States. Clin J Am Soc Nephrol 2019; 14:1500-1511. [PMID: 31413065 PMCID: PMC6777592 DOI: 10.2215/cjn.03140319] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 07/02/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND OBJECTIVES Long wait times for deceased donor kidneys and low rates of preemptive wait-listing have limited preemptive transplantation in the United States. We aimed to assess trends in preemptive deceased donor transplantation with the introduction of the new Kidney Allocation System (KAS) in 2014 and identify whether key disparities in preemptive transplantation have changed. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We identified adult deceased donor kidney transplant recipients in the United States from 2000 to 2018 using the Scientific Registry of Transplant Recipients. Preemptive transplantation was defined as no dialysis before transplant. Associations between recipient, donor, transplant, and policy era characteristics and preemptive transplantation were calculated using logistic regression. To test for modification by KAS policy era, an interaction term between policy era and each characteristic of interest was introduced in bivariate and adjusted models. RESULTS The proportion of preemptive transplants increased after implementation of KAS from 9.0% to 9.8%, with 1.10 (95% confidence interval [95% CI], 1.06 to 1.14) times higher odds of preemptive transplantation post-KAS compared with pre-KAS. Preemptive recipients were more likely to be white, older, female, more educated, hold private insurance, and have ESKD cause other than diabetes or hypertension. Policy era significantly modified the association between preemptive transplantation and race, age, insurance status, and Human Leukocyte Antigen zero-mismatch (interaction P<0.05). Medicare patients had a significantly lower odds of preemptive transplantation relative to private insurance holders (pre-KAS adjusted OR, [aOR] 0.26; [95% CI, 0.25 to 0.27], to 0.20 [95% CI, 0.18 to 0.22] post-KAS). Black and Hispanic patients experienced a similar phenomenon (aOR 0.48 [95% CI, 0.45 to 0.51] to 0.41 [95% CI, 0.37 to 0.45] and 0.43 [95% CI, 0.40 to 0.47] to 0.40 [95% CI, 0.36 to 0.46] respectively) compared with white patients. CONCLUSIONS Although the proportion of deceased donor kidney transplants performed preemptively increased slightly after KAS, disparities in preemptive kidney transplantation persisted after the 2014 KAS policy changes and were exacerbated for racial minorities and Medicare patients.
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Affiliation(s)
- Kristen L King
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York.,The Columbia University Renal Epidemiology (CURE) Group, New York, New York
| | - Syed Ali Husain
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York.,The Columbia University Renal Epidemiology (CURE) Group, New York, New York
| | | | - Corey Brennan
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York; .,The Columbia University Renal Epidemiology (CURE) Group, New York, New York.,Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
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Living donor kidney transplantation: often a missed opportunity. Br J Gen Pract 2019; 69:428-429. [PMID: 31467004 DOI: 10.3399/bjgp19x705173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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15
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Gruessner RWG, Gruessner AC. Solid-organ Transplants From Living Donors: Cumulative United States Experience on 140,156 Living Donor Transplants Over 28 Years. Transplant Proc 2019; 50:3025-3035. [PMID: 30577162 DOI: 10.1016/j.transproceed.2018.07.024] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Transplantation of organs from living donors helps to decrease the organ shortage and shortens waiting times. Living donor (LD) transplantation is also generally associated with better outcomes. Unfortunately, there has been no comprehensive analysis and comparison of all types of solid-organ transplantation from living donors since the inception of the United Network for Organ Sharing (UNOS). METHODS Using the UNOS/Organ Procurement and Transplantation Network (OPTN) database, all LD transplants from October 1, 1987, to December 31, 2015, were studied with univariate and multivariate analyses. RESULTS A total of 140,090 organs were transplanted from LDs, accounting for 21% of all transplants in the United States. Over 95% were kidney; 4% were liver; and <1% intestine, lung, and pancreas LDs. Only LD kidney transplant patient and graft survival rates were significantly higher compared deceased donor transplants over the period of analysis. The best long-term LD transplant results were achieved in pediatric liver recipients. Significantly more women than men donated organs and significantly more men than women received solid-organ transplants. A regional disparity was observed for LD kidney as well as for LD liver transplants. Despite improvements in outcomes and increased use of nonbiologic donors, the number of LD transplants in the United States has declined. This decline was greater in children than adults and was noted for all types of organ transplants. CONCLUSION Further efforts are needed to educate the public, health professionals, and transplant candidates on the advantages of living vs deceased donor organ transplantation. Compared with other countries, LD transplantation has yet to reach its full potential in the United States.
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Affiliation(s)
- R W G Gruessner
- Department of Surgery, SUNY Downstate Medical Center, Brooklyn, NY.
| | - A C Gruessner
- Department of Medicine, SUNY Downstate Medical Center, Brooklyn, NY
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Abstract
The best treatment option for many patients with kidney failure is a kidney transplant from a living donor. Countries that successfully increase their rate of living kidney donation will decrease their reliance on dialysis, the most expensive and high-risk form of kidney replacement therapy. Outlined here are some barriers that prevent some patients from pursuing living kidney donation and current knowledge on some potential solutions to these barriers. Also described are strategies to promote living kidney donation in a defensible system of practice. Safely increasing the rate of living kidney donation will require better programs and policies to improve the experiences of living donors and their recipients, to safeguard the practice for years to come.
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Affiliation(s)
- Amit X Garg
- Department of Medicine, Epidemiology and Biostatistics, Western University, London, Ontario, Canada
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Gritane K, Jusinskis J, Malcevs A, Suhorukovs V, Amerika D, Puide I, Ziedina I. Influence of Pretransplant Dialysis Vintage on Repeated Kidney Transplantation Outcomes. Transplant Proc 2018; 50:1249-1257. [PMID: 29880343 DOI: 10.1016/j.transproceed.2018.01.056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Revised: 12/20/2017] [Accepted: 01/23/2018] [Indexed: 01/17/2023]
Abstract
Dialysis has a dose-dependent effect on first kidney transplantation outcomes, and a shorter waiting time on dialysis is associated with superior graft function. There are not enough data to support this statement in the case of a repeated transplantation. As such, we aimed to evaluate the influence of the dialysis vintage before the last transplantation on graft function as well as patient and graft survival in repeated transplantation situations. Patients who underwent repeated kidney transplantations were included in the retrospective study. Specifically, 79 patients were included who were divided into 4 groups according to the dialysis vintage before the last transplantation. We assessed graft function and patient and graft survival rates after 1- and 3-year follow-up. One-year graft function was worse for patients with a dialysis vintage of more than 31 months (P = .005), but there was no difference after 3 years. One- and 3-year graft survival was better for patients with a dialysis vintage of less than 12 months (P = .017). We concluded that a longer waiting time on dialysis was associated with worse graft function and diminished long-term graft survival after repeated kidney transplantation.
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Affiliation(s)
- K Gritane
- Riga Stradins University, Transplant Research Laboratory, Riga, Latvia
| | - J Jusinskis
- Riga Stradins University, Transplant Research Laboratory, Riga, Latvia; Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - A Malcevs
- Riga Stradins University, Transplant Research Laboratory, Riga, Latvia; Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - V Suhorukovs
- Riga Stradins University, Transplant Research Laboratory, Riga, Latvia; Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - D Amerika
- Riga Stradins University, Transplant Research Laboratory, Riga, Latvia; Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - I Puide
- Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - I Ziedina
- Riga Stradins University, Transplant Research Laboratory, Riga, Latvia; Pauls Stradins Clinical University Hospital, Riga, Latvia.
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Cost analysis of substitutive renal therapies in children. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2018. [DOI: 10.1016/j.jpedp.2017.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Camargo MFCD, Barbosa KDS, Fetter SK, Bastos A, Feltran LDS, Koch-Nogueira PC. Cost analysis of substitutive renal therapies in children. J Pediatr (Rio J) 2018; 94:93-99. [PMID: 28750890 DOI: 10.1016/j.jped.2017.05.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 04/19/2017] [Accepted: 02/27/2017] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE End-stage renal disease is a health problem that consumes public and private resources. This study aimed to identify the cost of hemodialysis (either daily or conventional hemodialysis) and transplantation in children and adolescents. METHODS This was a retrospective cohort of pediatric patients with End-stage renal disease who underwent hemodialysis followed by kidney transplant. All costs incurred in the treatment were collected and the monthly total cost was calculated per patient and for each renal therapy. Subsequently, a dynamic panel data model was estimated. RESULTS The study included 30 children who underwent hemodialysis (16 conventional/14 daily hemodialysis) followed by renal transplantation. The mean monthly outlay for hemodialysis was USD 3500 and USD 1900 for transplant. Hemodialysis costs added up to over USD 87,000 in 40 months for conventional dialysis patients and USD 131,000 in 50 months for daily dialysis patients. In turn, transplant costs in 50 months reached USD 48,000 and USD 70,000, for conventional and daily dialysis patients, respectively. For conventional dialysis patients, transplant is less costly when therapy exceeds 16 months, whereas for daily dialysis patients, the threshold is around 13 months. CONCLUSION Transplantation is less expensive than dialysis in children, and the estimated thresholds indicate that renal transplant should be the preferred treatment for pediatric patients.
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Affiliation(s)
| | | | | | - Ana Bastos
- Hospital Samaritano, São Paulo, SP, Brazil
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20
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Sade R, Kantarci M, Karaca L, Okur A, Ogul H, Keles M, Çankaya E, Ayan AK. Value of dynamic MRI using the Ktrans technique for assessment of native kidneys in pre-emptive renal transplantation. Acta Radiol 2017; 58:1005-1011. [PMID: 27864568 DOI: 10.1177/0284185116678272] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Background Different non-invasive imaging techniques such as Doppler ultrasonography and renal scintigraphy are commonly employed to assess allograft function and associated complications. However, all such methods lack sufficient specificity to discriminate between residual renal function of native kidneys. Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) evaluates signal dynamics during the passage of contrast material through the renal cortex, medulla, and collecting system. Purpose To investigate the value of DCE 3T MRI using a quantitative pharmacokinetic parameter (Ktrans) for the assessment of native kidneys before and after pre-emptive renal transplantation. Material and Methods Twenty-five consecutive patients with end-stage renal disease underwent DCE MRI before and 6 months after kidney transplantation. MRI was performed using a 3T scanner. Regions of interests were drawn over each kidney, encompassing the cortex and medulla but excluding the collecting system and any coexisting cysts. Parametric Ktrans values were automatically generated. Results In the pre-transplantation group, mean Ktrans values for the right and left kidneys were 0.55 ± 0.09 min-1 and 0.44 ± 0.15 min-1, respectively. In the post-transplantation group, mean Ktrans values of the right and left kidneys were 0.27 ± 0.07 min-1 and 0.25 ± 0.10 min-1, respectively. There were statistically significant differences between right and left kidneys in terms of mean Ktrans values in the pre- and post-transplantation groups ( P < 0.001). Conclusion Our preliminary results show that native kidneys were still functioning 6 months after transplantation. MR perfusion using Ktrans may constitute a non-invasive means of determination of the viability of native kidneys after renal transplantation.
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Affiliation(s)
- Recep Sade
- AtaturkUniversity, School of Medicine, Department of Radiology, Erzurum, Turkey
| | - Mecit Kantarci
- AtaturkUniversity, School of Medicine, Department of Radiology, Erzurum, Turkey
| | - Leyla Karaca
- AtaturkUniversity, School of Medicine, Department of Radiology, Erzurum, Turkey
| | - Aylin Okur
- Bozok University, School of Medicine, Department of Radiology, Yozgat, Turkey
| | - Hayri Ogul
- AtaturkUniversity, School of Medicine, Department of Radiology, Erzurum, Turkey
| | - Mustafa Keles
- AtaturkUniversity, School of Medicine, Department of Internal Medicine, Division of Nephrology, Erzurum, Turkey
| | - Erdem Çankaya
- AtaturkUniversity, School of Medicine, Department of Internal Medicine, Division of Nephrology, Erzurum, Turkey
| | - Arif Kursad Ayan
- AtaturkUniversity, School of Medicine, Department of Nuclear Medicine, Erzurum, Turkey
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21
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Reassessing Preemptive Kidney Transplantation in the United States: Are We Making Progress? Transplantation 2017; 100:1120-7. [PMID: 26479285 DOI: 10.1097/tp.0000000000000944] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Preemptive kidney transplantation (preKT) is associated with higher patient survival, improved quality of life, and lower costs. However, only a minority of patients receives preKT. The aim of this study was to examine changes over the past decade in rates of preKT, focusing on living donor kidney transplantation (LDKT) and specifically recipients who underwent kidney transplantation within 1 year of initiating dialysis. METHODS Using United Network of Organ Sharing data, we examined retrospectively all kidney transplant candidates (n = 369 103) and recipients (n = 141 254) from 2003 to 2012 in the United States focusing on LDKT (n = 47 108). Predictors of preKT were examined, and patient and graft survival were compared for preKT, pretransplant dialysis less than 1 year, and pretransplant dialysis recipients of 1 year or longer. RESULTS PreKT occurred in only 17% of recipients overall and 31% of LDKT recipients. Medicare patients (odds ratio [OR], 0.29; 95% confidence interval [95% CI], 0.28-0.31), diabetics (OR, 0.75; 95% CI, 0.69-0.80), and minorities (Hispanics OR, 0.62; 95% CI, 0.57-0.68 and African Americans OR, 0.58; 95% CI, 0.53-0.63) were less likely to receive preKT. Dialysis recipients for less than 1 year comprised 30% of nonpreemptive LDKT. Dialysis recipients of less than 1 year had similar patient survival to preKT (5 years: preKT, 94%; dialysis < 1 year, 94%; dialysis ≥ 1 year, 89%; P < 0.01), but decreased death-censored graft survival (5 years: preKT, 93%; dialysis < 1 year, 89%; and dialysis ≥ 1 year, 89%; P < 0.01). CONCLUSIONS PreKT remains an unrealized goal for the majority of recipients. Medicare patients, diabetics, and minorities are less likely to receive preKT. Almost one third of nonpreemptive LDKT recipients were dialyzed for less than 1 year, highlighting an important target for improvement.
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Tandon A, Wang M, Roe KC, Patel S, Ghahramani N. Nephrologists' likelihood of referring patients for kidney transplant based on hypothetical patient scenarios. Clin Kidney J 2016; 9:611-5. [PMID: 27478607 PMCID: PMC4957715 DOI: 10.1093/ckj/sfw031] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 04/08/2016] [Indexed: 01/04/2023] Open
Abstract
Background There is wide variation in referral for kidney transplant and preemptive kidney transplant (PKT). Patient characteristics such as age, race, sex and geographic location have been cited as contributing factors to this disparity. We hypothesize that the characteristics of nephrologists interplay with the patients' characteristics to influence the referral decision. In this study, we used hypothetical case scenarios to assess nephrologists' decisions regarding transplant referral. Methods A total of 3180 nephrologists were invited to participate. Among those interested, 252 were randomly selected to receive a survey in which nephrologists were asked whether they would recommend transplant for the 25 hypothetical patients. Logistic regression models with single covariates and multiple covariates were used to identify patient characteristics associated with likelihood of being referred for transplant and to identify nephrologists' characteristics associated with likelihood of referring for transplant. Results Of the 252 potential participants, 216 completed the survey. A nephrologist's affiliation with an academic institution was associated with a higher likelihood of referral, and being ‘>10 years from fellowship’ was associated with lower likelihood of referring patients for transplant. Patient age <50 years was associated with higher likelihood of referral. Rural location and smoking history/chronic obstructive pulmonary disease were associated with lower likelihood of being referred for transplant. The nephrologist's affiliation with an academic institution was associated with higher likelihood of referring for preemptive transplant, and the patient having a rural residence was associated with lower likelihood of being referred for preemptive transplant. Conclusions The variability in transplant referral is related to patients' age and geographic location as well as the nephrologists' affiliation with an academic institution and time since completion of training. Future educational interventions should emphasize the benefits of kidney transplant and PKT for all population groups regardless of geographic location and age and should target nephrologists in non-academic settings who are 10 or more years from their fellowship training.
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Affiliation(s)
- Ankita Tandon
- Department of Medicine , Pennsylvania State University College of Medicine , Hershey , PA , USA
| | - Ming Wang
- Department of Public Health Sciences , Pennsylvania State University College of Medicine , Hershey , PA , USA
| | - Kevin C Roe
- Division of Nephrology, Department of Medicine , Pennsylvania State University College of Medicine , Hershey , PA , USA
| | - Surju Patel
- Division of Nephrology, Department of Medicine , Pennsylvania State University College of Medicine , Hershey , PA , USA
| | - Nasrollah Ghahramani
- Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, PA, USA; Division of Nephrology, Department of Medicine, Pennsylvania State University College of Medicine, Hershey, PA, USA
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Abstract
Late referral of patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) for evaluation of kidney transplantation is common. Even though renal transplantation offers a clear survival benefit to patients with advanced CKD and ESRD and should be considered the renal replacement therapy of choice, numerous barriers to early renal transplant referral have been observed. Some of these barriers can be overcome by improving the communication between the referring providers and the transplant centers. Furthermore, providing more intensive education to both patients and referring providers with regard to the eligibility of CKD and ESRD patients for a transplant will likely result in higher referral rates. This in turn will lead to improved survival outcomes in this group of patients with otherwise significantly increased morbidity and mortality.
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Affiliation(s)
- Vasil Peev
- Department of Medicine, University Transplant Program, Rush University Medical Center, Chicago, Illinois
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Arze Aimaretti L, Arze S. Preemptive Renal Transplantation—The Best Treatment Option for Terminal Chronic Renal Failure. Transplant Proc 2016; 48:609-11. [PMID: 27110013 DOI: 10.1016/j.transproceed.2016.02.047] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abramowicz D, Hazzan M, Maggiore U, Peruzzi L, Cochat P, Oberbauer R, Haller MC, Van Biesen W. Does pre-emptive transplantation versus post start of dialysis transplantation with a kidney from a living donor improve outcomes after transplantation? A systematic literature review and position statement by the Descartes Working Group and ERBP. Nephrol Dial Transplant 2015; 31:691-7. [PMID: 26567249 DOI: 10.1093/ndt/gfv378] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 10/08/2015] [Indexed: 12/21/2022] Open
Abstract
This position statement brings up guidance on pre-emptive kidney transplantation from living donors. The provided guidance is based on a systematic review of the literature.
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Affiliation(s)
- Daniel Abramowicz
- Descartes Working Group of ERA-EDTA, London, UK Nephrology Department, Antwerp University Hospital, Antwerp, Belgium
| | - Marc Hazzan
- Descartes Working Group of ERA-EDTA, London, UK Service de Néphrologie, Hôpital Huriez, CHRU, Lille, France
| | - Umberto Maggiore
- Descartes Working Group of ERA-EDTA, London, UK Kidney and Kidney-Pancreas Transplant Unit (Nephrology Department), Parma University Hospital, Parma, Italy
| | - Licia Peruzzi
- Descartes Working Group of ERA-EDTA, London, UK Nephrology Dialysis and Transplantation, Regina Margherita Children's Hospital, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Pierre Cochat
- Descartes Working Group of ERA-EDTA, London, UK Centre de Référence des Maladies Rénales Rares, Université Claude Bernard, Lyon, France
| | - Rainer Oberbauer
- Descartes Working Group of ERA-EDTA, London, UK Department of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Maria C Haller
- Methods Support Team ERBP, Ghent University Hospital, Ghent, Belgium Department of Internal Medicine III, Nephrology and Hypertension Diseases, Transplantation Medicine and Rheumatology, Krankenhaus Elisabethinen, Linz, Austria
| | - Wim Van Biesen
- Methods Support Team ERBP, Ghent University Hospital, Ghent, Belgium Renal Division, Ghent University Hospital, Ghent, Belgium
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Abstract
BACKGROUND Kidney transplantation is the best treatment method for end-stage renal disease. Outcomes of the preemptive kidney transplantation are better than non-preemptive kidney transplantation. Preemptive kidney transplantation is performed as a small percentage of kidney transplantations worldwide. We performed 15 preemptive kidney transplantations from living donors between November 2010 and April 2014. We present our experiences and outcomes for these 15 preemptive kidney transplantations. METHODS We performed 110 kidney transplantations between November 2010 and April 2014. Fifteen of the kidney transplantations were performed from living related donors to preemptive recipients. These 15 preemptive recipients and their donors' data were collected and retrospectively analyzed. RESULTS The mean age of recipients and donors was 37.2 years (range, 4-60) and 50.6 years (range, 28-64), respectively. The male-female ratios were 10:5 in the recipients and 8:7 in the donors. Nine left kidneys and 6 right kidneys were recovered. Nine kidneys had a single artery; the other 6 kidneys had 2 renal arteries. The mean warm ischemic time was 219.5 seconds (range, 90-480). The mean hospitalization times were 5.9 days (range, 4-10) and 4.9 days (range, 3-9) for the recipients and the donors, respectively. The mean follow-up time was 20.3 months (range, 0.5-37) for recipients. Graft survival was 100% in this period. BK virus nephropathy occurred in only 1 pediatric recipient. One patient had a recurrent disease that was the cause of the renal failure. They graft functions were stable. No kidney was lost from rejection, technical causes, infection, or recurrent disease. The donors live their lives with no problems. CONCLUSIONS Preemptive kidney transplantation is a better therapeutic option than is non-preemptive kidney transplantation for patients with chronic renal failure. Kidney transplantation should be performed if possible before beginning dialysis for these patients.
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Soylu H, Oruc M, Demirkol O, Saygili E, Ataman R, Altiparmak M, Pekmezci S, Seyahi N. Survival of Renal Transplant Patients: Data From a Tertiary Care Center in Turkey. Transplant Proc 2015; 47:348-53. [DOI: 10.1016/j.transproceed.2014.10.054] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Revised: 10/09/2014] [Accepted: 10/28/2014] [Indexed: 01/30/2023]
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Patzer RE, Sayed BA, Kutner N, McClellan WM, Amaral S. Racial and ethnic differences in pediatric access to preemptive kidney transplantation in the United States. Am J Transplant 2013; 13:1769-81. [PMID: 23731389 PMCID: PMC3763919 DOI: 10.1111/ajt.12299] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Revised: 03/20/2013] [Accepted: 03/31/2013] [Indexed: 01/25/2023]
Abstract
Preemptive kidney transplantation is the optimal treatment for pediatric end stage renal disease patients to avoid increased morbidity and mortality associated with dialysis. It is unknown how race/ethnicity and poverty influence preemptive transplant access in pediatric. We examined the incidence of living donor or deceased donor preemptive transplantation among all black, white, and Hispanic children (<18 years) in the United States Renal Data System from 2000 to 2009. Adjusted risk ratios for preemptive transplant were calculated using multivariable-adjusted models and examined across health insurance and neighborhood poverty levels. Among 8,053 patients, 1117 (13.9%) received a preemptive transplant (66.9% from LD, 33.1% from DD). In multivariable analyses, there were significant racial/ethnic disparities in access to LD preemptive transplant where blacks were 66% (RR = 0.34; 95% CI: 0.28-0.43) and Hispanics 52% (RR = 0.48; 95% CI: 0.35-0.67) less likely to receive a LD preemptive transplant versus whites. Blacks were 22% less likely to receive a DD preemptive transplant versus whites (RR = 0.78, 95% CI: 0.57-1.05), although results were not statistically significant. Future efforts to promote equity in preemptive transplant should address the critical issues of improving access to pre-ESRD nephrology care and overcoming barriers in living donation, including obstacles partially driven by poverty.
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Affiliation(s)
- Rachel E Patzer
- Emory University, Department of Surgery, Emory Transplant Center, Atlanta, GA,Emory University, Rollins School of Public Health, Department of Epidemiology, Atlanta, GA
| | - Blayne A Sayed
- Emory University, Department of Surgery, Emory Transplant Center, Atlanta, GA
| | - Nancy Kutner
- Emory University, USRDS Rehabilitation/QoL Special Studies Center, Atlanta, GA
| | - William M McClellan
- Emory University, Rollins School of Public Health, Department of Epidemiology, Atlanta, GA,Emory University, Division of Nephrology, WMB, Room 338, 1639 Pierce Dr., Atlanta, GA 30322
| | - Sandra Amaral
- The Children's Hospital of Philadelphia, University of Pennsylvania, Perelman School of Medicine, Department of Pediatrics and Department of Biostatistics and Epidemiology, Philadelphia, PA
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Abstract
Solid organ transplantations save lives in patients affected by terminal organ failures and improve quality of life. Organ transplantations have gradually ameliorated in the last two decades and usually provide excellent results in children and young adults, and are increasingly challenged by the growing proportion of elderly transplant patients with comorbidities. Renal transplantation increases patient survival over dialysis, and lifesaving transplants are indispensible to treat patients with liver, heart, or lung irreversible diseases. Solid organ transplant programs activity has been steadily growing but is still far from global needs, with great differences among countries. Solid organ transplantations are essential for developed and mature health care systems.
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Affiliation(s)
- Josep M Grinyó
- Department of Nephrology, Hospital Universitari de Bellvitge, IDIBELL, University of Barcelona, Barcelona 08907, Spain.
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31
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Wiseman AC, Huang E, Kamgar M, Bunnapradist S. The impact of pre-transplant dialysis on simultaneous pancreas–kidney versus living donor kidney transplant outcomes. Nephrol Dial Transplant 2013; 28:1047-58. [DOI: 10.1093/ndt/gfs582] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Ficorelli CT, Edelman M, Weeks BH. Living donor renal transplant: a gift of life. Nursing 2012; 43:58-62. [PMID: 23254882 DOI: 10.1097/01.nurse.0000423962.53249.b1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Pretagostini R, Ricci A, Gabbrielli F, Lai Q, Stabile D, Puoti F, Fiaschetti P, Oliveti A, Peritore D, Rizzato L, Nanni CA. Living organ donation, a therapeutic possibility, is still poorly used in Italy: a national analysis. Transplant Proc 2012; 44:1818-1819. [PMID: 22974845 DOI: 10.1016/j.transproceed.2012.06.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Validity of living donor kidney transplantation is universally accepted. In contrast, after enthusiastic adoption in the 1990s, living donor liver transplantation has decreased in recent years. The aim of the present study was to evaluate retrospectively the current use of this form of donation in Italy by comparing liver and kidney cadaveric and living donations from 2002 to 2010. The number of liver transplantations from living donors has decreased from 34 in 2002 (3.9% of total) to 13 in 2010 (1.3% of total). In contrast, kidney transplantation from living donors increased from 126 (7.9% of total) to 186 (11% of total). We observed that living donations for kidney transplantation are still underused, especially with unrelated donors. Living donor liver transplantation has decreased in recent years; this procedure should be reserved to centers with particular expertise. It would be appropriate to implement programs to increase the attention of health professionals and the general population and to integrate living donations into programs of deceased organ donation.
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Affiliation(s)
- R Pretagostini
- Interregional Centre Organizzazione Centro-Sud Trapianti, Surgery Sciences Department of Policlinico of Rome Umberto I, Rome, Italy.
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Ross LF, Parker W, Veatch RM, Gentry SE, Thistlethwaite JR. Equal Opportunity Supplemented by Fair Innings: equity and efficiency in allocating deceased donor kidneys. Am J Transplant 2012; 12:2115-24. [PMID: 22703559 DOI: 10.1111/j.1600-6143.2012.04141.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
For 7 years, the Kidney Transplantation Committee of the United Network for Organ Sharing/Organ Procurement Transplantation Network has attempted to revise the kidney allocation algorithm for adults (≥18 years) in end-stage renal disease awaiting deceased donor kidney transplants. Changes to the kidney allocation system must conform to the 1984 National Organ Transplant Act (NOTA) which clearly states that allocation must take into account both efficiency (graft and person survival) and equity (fair distribution). In this article, we evaluate three allocation models: the current system, age-matching and a two-step model that we call "Equal Opportunity Supplemented by Fair Innings (EOFI)". We discuss the different conceptions of efficiency and equity employed by each model and evaluate whether EOFI could actually achieve the NOTA criteria of balancing equity and efficiency given current conditions of growing scarcity and donor-candidate age mismatch.
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Affiliation(s)
- L F Ross
- Department of Pediatrics, University of Chicago, Chicago, IL, USA.
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Preemptive kidney transplantation: has it come of age? Nephrol Ther 2012; 8:428-32. [PMID: 22841863 DOI: 10.1016/j.nephro.2012.06.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Revised: 06/08/2012] [Accepted: 06/15/2012] [Indexed: 11/23/2022]
Abstract
The benefits of preemptive kidney transplantation are manifold. By avoiding complications associated with dialysis, preemptive kidney transplantation offers significant benefits in terms of patient welfare and societal cost-saving. Patients transplanted preemptively also tend to enjoy better patient and graft survival, especially when done with a living-donor organ. While dialysis exposure limited to 6 to 12 months may not significantly impact post-transplant outcomes, longer period of dialysis has been shown to increase the risk of mortality, delayed graft function, acute rejection, and death-censored graft loss. The benefits of preemptive transplantation also extend to different age groups and end-stage kidney disease (ESKD) diagnoses. However, multiple barriers have prevented wider adoption of preemptive transplantation as the primary treatment of ESKD around the world. Timely preparation for ESKD and identification of living donors should be encouraged in all patients with advanced chronic kidney disease to increase the chance of preemptive transplantation.
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Joshi S, J Gaynor J, Ciancio G. Review of ethnic disparities in access to renal transplantation. Clin Transplant 2012; 26:E337-43. [PMID: 22775991 DOI: 10.1111/j.1399-0012.2012.01679.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2012] [Indexed: 11/28/2022]
Abstract
Renal transplantation is the gold standard treatment for patients with end-stage renal disease and is associated with several advantages over dialysis, including increased quality of life, reduced morbidity and mortality, and lower healthcare costs. Barring the constraints of a limited organ supply, the goals of the patient care should focus on attaining renal transplantation while minimizing, or even eliminating, time spent on dialysis. Disparities in access to renal transplantation between African Americans and Caucasians have been extensively documented, with African Americans having significantly poorer access. There is a growing corpus of literature examining the determinants of reduced access among other racial ethnic minority groups, including Hispanics. These determinants include patient and physician preference, socioeconomic status, insurance type, patient education, and immunologic factors. We review these determinants in access to renal transplantation in the United States among all races and ethnicities.
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Affiliation(s)
- Shivam Joshi
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
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Clinical features and outcomes of 98 children and adults with dense deposit disease. Pediatr Nephrol 2012; 27:773-81. [PMID: 22105967 PMCID: PMC4423603 DOI: 10.1007/s00467-011-2059-7] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2011] [Revised: 10/12/2011] [Accepted: 10/13/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND Dense deposit disease (DDD) is an ultra-rare renal disease. METHODS In the study reported here, 98 patients and their families participated in a descriptive patient-centered survey using an online research format. Reports were completed by patients (38%) or their parents (62%). Age at diagnosis ranged from 1.9 to 38.9 years (mean 14 years). RESULTS The majority of patients presented with proteinuria and hematuria; 50% had hypertension and edema. Steroids were commonly prescribed, although their use was not evidence-based. One-half of the patients with DDD for 10 years progressed to end-stage renal disease (ESRD), with young females having the greatest risk for renal failure. Of first allografts, 45% failed within 5 years, most frequently due to recurrent disease (70%). Type 1 diabetes (T1D) was present in over 16% of families, which represents a 116-fold increase in incidence compared with the general population (p < 0.001). CONCLUSIONS Based on these findings, we suggest that initiatives are needed to explore the high incidence of T1D in family members of DDD patients and the greater risk for progression to ESRD in young females with DDD. These efforts must be supported by sufficient numbers of patients to establish evidence-based practice guidelines for disease management. An international collaborative research survey should be implemented to encourage broad access and participation.
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Langzeitüberleben bei chronischer Niereninsuffizienz. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2012; 55:543-51. [DOI: 10.1007/s00103-012-1450-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Outcomes of preemptive kidney with or without subsequent pancreas transplant compared with preemptive simultaneous pancreas/kidney transplantation. Transplantation 2011; 92:1115-22. [PMID: 21959215 DOI: 10.1097/tp.0b013e31823328a6] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Prior studies have indicated that type 1 diabetic (T1DM) recipients of a simultaneous pancreas-kidney (SPK) transplant have greater short-term mortality compared with living donor kidney (LDK) transplantation. Whether this association remains and how outcomes compare to deceased donor kidney (DDK) transplantation in the preemptive setting are unknown. METHODS Using data on recipients transplanted between 2000 and 2010 from the Organ Procurement and Transplantation Network/United Network of Organ Sharing, patient and graft survival (calculated from the time of kidney transplant) of pancreas after preemptive LDK (PALK, n=389), preemptive LDK not receiving a pancreas transplant (LDK/noP, n=289), preemptive DDK (n=112), and preemptive SPK transplantations (n=1402) were compared. RESULTS At 6 years, patient survival was excellent (PALK=89.4%, LDK/noP=84.9%, DDK=81.2%, and SPK=91.1%) and not different between PALK, LDK/noP, and SPK (P value vs. PALK: LDK/noP=0.08; SPK=0.85) but was lower with preemptive DDK versus preemptive PALK (P=0.03). When both LDK groups were considered together, there was higher mortality in the first 180 days after transplant with preemptive DDK (3.7% vs. 1.1%; P=0.03) and similar mortality with preemptive SPK (2.3%; P=0.07). After multivariate adjustment, there was a trend toward increased risk of death with preemptive DDK compared with preemptive PALK (hazard ratio: 1.91; 95% confidence interval: 0.95-3.84). CONCLUSIONS Patient survival associated with preemptive transplantation among T1DM recipients was excellent at 6 years, with the greatest survival favoring PALK, LDK/noP, and SPK rather than DDK. In contrast with prior studies reporting greater short-term mortality with SPK among the general T1DM population, short-term mortality after preemptive transplant is similar between LDK and SPK.
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Chamienia A, Dębska-Ślizień A, Rutkowski B, Zadrożny D, Moszkowska G. 11-Year Single-Center Experience in Living-Donor Kidney Transplantation in Poland. Transplant Proc 2011; 43:2911-3. [DOI: 10.1016/j.transproceed.2011.08.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Grams ME, Massie AB, Coresh J, Segev DL. Trends in the timing of pre-emptive kidney transplantation. J Am Soc Nephrol 2011; 22:1615-20. [PMID: 21617118 PMCID: PMC3171933 DOI: 10.1681/asn.2011010023] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2011] [Accepted: 03/21/2011] [Indexed: 11/03/2022] Open
Abstract
Pre-emptive kidney transplantation is considered the best available renal replacement therapy, but no guidelines exist to direct its timing during CKD progression. We used a national cohort of 19,471 first-time pre-emptive kidney transplant recipients between 1995-2009 to evaluate patterns and implications of transplant timing. Mean estimated GFR (eGFR) at the time of pre-emptive transplant increased significantly over time, from 9.2 ml/min/1.73 m(2) in 1995 to 13.8 ml/min/1.73 m(2) in 2009 (P<0.001). Patients with eGFR ≥ 15 ml/min/1.73 m(2) represented an increasing proportion of pre-emptive transplant recipients, from 9% in 1995 to 35% in 2009; the trend for patients with eGFR ≥ 10 was similar (30% to 72%). We did not detect statistically significant differences in patient survival or death-censored graft survival between strata of eGFR at the time of transplant, either in the full cohort or in subgroup analyses of patients who might theoretically benefit from earlier pre-emptive transplantation. In summary, pre-emptive kidney transplantation is occurring at increasing levels of native kidney function. Earlier transplantation does not appear to associate with patient or graft survival, suggesting that earlier pre-emptive transplantation may subject donors and recipients to premature operative risk and waste the native kidney function of recipients.
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Affiliation(s)
- Morgan E Grams
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
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