Systematic review: kidney transplantation compared with dialysis in clinically relevant outcomes

Use of Anti-interleukin-1 Agents in Kidney Transplant Recipients with Familial Mediterranean Fever and Amyloidosis: What have been learned so far?

Purpose of Review

Familial Mediterranean fever (FMF) is the most common monogenic auto-inflammatory disease causing amyloidosis (AA type) which may result in development of end-stage kidney disease (ESKD). Colchicine is the initial treatment option for patients FMF/amyloidosis both before and after KT. Although, kidney transplantation (KT) can be offered to patients with ESKD due to FMF/amyloidosis, FMF attacks did not resolve in some of kidney transplant recipients (KTRs) and de-novo development of amyloidosis after KT may be observed despite colchicine treatment. For these patients, other treatment options are warranted including anti-interleukin-1 agents such as anakinra and canakinumab. The purpose of the review is to summarize the use of anti-interleukin-1 agents in KTRs with FMF and amyloidosis.

Recent Findings

Recent studies showed that these agents are effective in KTRs in terminating FMF attacks and decreasing inflammatory parameters. Furthermore, no significant interaction with immunosuppressive drugs were recorded and side effects were few. However, there are various knowledge gaps.

Physical activity interventions in adult kidney transplant recipients: an updated systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Kidney transplant recipients (KTRs) exhibit a high prevalence of cardiovascular disease (CVD) and adverse changes in physical fitness and body composition. Post-transplant management recommends being physically active and evidence in this field is growing. The aim of this review was to update our previous systematic review and meta-analysis of randomized controlled trials (RCTs) assessing the effects of physical activity and exercise training interventions in KTRs.

METHODS

A comprehensive literature search between March 2021 and September 2024 identified seven additional RCTs. Therefore, this updated review and meta-analysis includes 23 RCTs. Outcomes included cardiorespiratory fitness (CRF), strength, blood pressure, body composition, heart rate, markers of dyslipidemia and kidney function, and health-related quality of life.

RESULTS

Twenty-three RCTs, including 1,139 KTRs, were included. The median intervention length was 12 weeks with participants exercising between 2 and 7×/week. Most studies used a mixture of aerobic and resistance training but reporting and intervention content was highly varied. Significant improvements were observed in CRF (V̇O2peak; +3.87 mL/kg/min, p = .0004), physical function (sit-to-stand-60; +7.72 repetitions, p = .0001), and high-density lipoprotein (HDL; +0.13 mmol/L, p = .02). Isolated studies reported improvements in strength, bone health, lean mass, and quality of life (QoL). All studies were found to have a high or moderate risk of bias.

CONCLUSIONS

Exercise training or increasing physical activity may confer several benefits in adult KTRs, especially through the improvements in CRF and HDL which have been linked to CVD risk. Despite new literature, there is still a need for long-term larger sampled RCTs and more detailed reporting of intervention details and program adherence.

Effect of eHealth Interventions on Medication Adherence in Kidney Transplant Recipients: Meta-Analysis of Randomised Controlled Trials

BACKGROUND

Kidney transplant recipients must take immunosuppressive drugs for life, and medication non-adherence is a primary risk factor for graft loss and death. With the advancement of technology, electronic health applications are widely used in chronic disease management and offer the potential to improve medication adherence in kidney transplant recipients.

AIM

This meta-analysis aims to evaluate randomised controlled trials (RCTs) that assess the effectiveness of eHealth interventions in improving medication adherence among kidney transplant recipients.

METHODS

This study, which was designed as a systematic review and meta-analysis, followed PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) protocols in the planning and reporting phases. Electronic databases and manual literature searches were the two main data sources. Full-text RCTs in PubMed, Medline, Web of Science and Scopus databases were systematically searched. The searches covered studies from 2014 to March 2024.

RESULTS

The search yielded 524 articles. Eight RCTs with 779 participants were included in the analysis. The meta-analysis results indicated that, compared with the control group, adherence rates (RR: 1.19; 95% CI: 1.06-1.35; p = 0.01. Heterogeneity: Q = 8.69; p = 0.28; I2 = 19%) and adherence scores (SMD: 0.17; 95% CI: 0.05-0.29; p = 0.02. Heterogeneity: Q = 0.45; p = 0.93; I2 = 0%) significantly increased in the eHealth intervention group compared with the control group.

CONCLUSION

The findings of this report show that eHealth interventions to improve medication adherence in kidney transplant recipients show favourable outcomes compared with standard care. We recommend eHealth interventions to improve long-term survival and patient outcomes in kidney transplant recipients.

Real needs of end-stage kidney disease patients awaiting kidney transplantation in China: A qualitative study

OBJECTIVE

To explore the true needs of patients awaiting kidney transplantation in China through the language used by them. We addressed the literature gap concerning this critical aspect of patient care and counselling.

METHODS

We interviewed 32 individuals-22 who were on the waiting list for a kidney transplant and 10 were kidney transplant recipients. The obtained data were analysed using Colaizzi seven-step method.

RESULTS

Four themes encompassing 86 coded statements were identified and crosschecked with each participant for validation.The waiting period needs of the participants fell into four distinct categories: emotional support, informational, medical support, and social support needs.

CONCLUSION

We can determine the needs of patients by interpreting their linguistic cues with a nuanced understanding.Transplant professionals must (1) understand patients' needs from their perspective; (2) recognise the dynamic changes in their emotional support demands; and (3) determine each patient's informational needs, their willingness to receive medical support, and the current state of their social support.

PRACTICE IMPLICATIONS

Our results offer insights for transplant professionals to better support patients awaiting kidney transplantation, highlighting the need to routinely attend to their unmet emotional, informational, medical and social support needs. This will enable patients to better prepare for transplantation while anticipating the arrival of a matched kidney.

Impact of corticosteroid withdrawal on bone mineral density after kidney transplantation

BACKGROUND

Bone abnormalities are common after kidney transplantation (KTx) and are associated with an increased risk of fractures. The pathophysiology of post-KTx bone disorders is multifactorial, with corticosteroid (CS) therapy being a contributor to the loss of bone mineral density (BMD). This study aimed to evaluate the impact of CS withdrawal versus continued CS therapy on BMD evolution in a kidney transplant recipients (KTRs) cohort.

METHODS

We retrospectively analyzed BMD data from 132 patients who underwent KTx between 2005 and 2021. BMD was assessed using dual-energy X-ray absorptiometry at the time of KTx (T0) and two-years post-KTx (2yT). Patients were categorized into two groups: those who discontinued CS (CS-) within the first-year post KTx and those who continued CS therapy (CS+).

RESULTS

The mean age at KTx was 52.2 (± 12.6) years, and 62.1% of the patients were male. Overall, BMD increased significantly at the lumbar spine (LS) but decreased at the radius at 2yT, while BMD at the hip site remained stable. CS was discontinued in 44.7% of patients between T0 and 2yT, with an average discontinuation time of 6.3 (± 4.9) months post-KTx. The CS- group showed significant BMD improvements at LS and hip sites. In a multivariate analysis, a higher cumulative CS dose was independently associated with a larger BMD decline.

CONCLUSIONS

CS withdrawal after KTx positively impacts BMD, while higher cumulative CS doses are associated with a greater BMD loss. These findings underscore the importance of minimizing CS exposure to preserve bone health in KTRs.

Clinic- and home-based renal rehabilitation improves spKt/V and uremic syndrome in hemodialysis patients: a case report

There was an increasing uptake of hemodialysis and patient life expectancy due to improved treatment efficiency. However, the quality of life (QOL) of chronic kidney disease (CKD) patients is not parallelly improved, leading to a shift in focus towards promoting the QOL. Among the common complications of CKD such as anaemia and mineral bone disorder, uremic syndrome has been found as the main contributor to poor QOL. We present the case of an 80-year-old man with hemodialysis, who presented with poor appetite and weakness following recovering from COVID-19. Biochemical, echocardiographic, body composition, psychological, nutritional, and QOL assessments suggested multi-organ dysfunction attributable to uremic syndrome. Renal rehabilitation involving the combination of clinic- and home-based exercise and nutritional interventions effectively improved his symptoms while elevating spKt/V. Our case report not only demonstrated exercise and nutritional rehabilitation as an effective approach to managing uremic syndrome in hemodialysis patients, but also provided insight into the effects of improved nutritional status on spKt/V.

System Interventions to Achieve Early and Equitable Kidney Transplants (STEPS): Protocol for STEPS, a randomized comparative effectiveness clinical trial

The System Interventions to Achieve Early and Equitable Kidney Transplants Study (STEPS) is an ongoing pragmatic clinical trial investigating the effectiveness of an equitable and patient-centered approach to kidney care on equitable access to early kidney transplants for individuals with chronic kidney disease not on dialysis. The STEPS intervention combines active electronic health record surveillance to equitably identify all potentially eligible kidney transplant candidates in three health systems ('STEPS Surveillance') with a 'STEPS Outreach Program' (comprised of equity-conscious patient-centered transplant social worker and transplant coordinator outreach and navigation activities). Identified eligible participants are randomly assigned to receive either (a) Augmented Usual Kidney Care (routine care plus electronic surveillance and best practice alerts), or (b) the STEPS Health System Surveillance and Outreach Intervention plus Augmented Usual Kidney Care to improve access to kidney transplants overall as well as among Black and rural residing individuals. STEPS recruited all planned 1168 participants from March 2022 to March 2024. Outcomes will quantify differences between the study arms in progress toward and completion of kidney transplant evaluations, assessed via medical records, and patient-reported outcomes. Registration of clinical trials This study is registered at ClinicalTrials.gov under the identifier NCT05014256.

Urinary biomarkers of kidney transplant rejection

PURPOSE OF REVIEW

Despite the introduction of many new immunosuppressive medications, allograft rejection remains a significant complication in transplantation. The use of "liquid biopsy" to evaluate allograft function and detect early rejection has recently become a prominent focus of investigation as it holds promise in providing noninvasive and immediate insights into the cellular and molecular makeup of the graft.

RECENT FINDINGS

In recent years, the introduction of molecular medicine along with the use of new technologies, including high-throughput techniques, has not only accelerated biomarker discovery but has also contributed to improving our understanding of the mechanisms underlying immune rejection. Genomics, transcriptomics, and metabolomics approaches, along with the increasing use of machine learning techniques, have paved the way for the discovery and development of novel biomarkers.

SUMMARY

Each year, there are hundreds of new biomarker discoveries in the publications. However, only a small fraction can be practically used as clinical tests or surrogate endpoints, receive FDA approval, and reach clinical application. Well designed and reproducible discovery and validation studies are rare and crucial. A contributing factor could be poor study design or quality of biospecimen repositories. In this review, we discuss urinary biomarkers of kidney allograft rejection that have shown promising findings but have yet to be successfully transitioned from bench to bedside.

[A rapid review: quality of life in adult allogeneic kidney transplantation in the last five years : What can we learn?]

BACKGROUND

Recent studies have also shown that clinical monitoring of quality of life (HRQoL) helps to recognize kidney transplant failure at an early stage.

OBJECTIVES

Given the potential of improving HRQoL for the long-term outcomes of kidney transplantation, we conducted a rapid review of the last 5 years of quality of life evaluation after adult allogeneic kidney transplantation.

MATERIALS AND METHODS

A rapid evidence analysis was carried out using a literature search in MEDLINE in the period 2019-2024.

RESULTS

The primary literature search yielded 554 hits, and ultimately only 12 cohort studies could be included, of which 2 were retrospective and 10 prospective cohort studies. Kidney transplant patients have better HRQoL than patients with end-stage renal disease. HRQoL is influenced by physical, psychological, and social factors. Further improvement of HRQoL or the primary influencing factors has the potential to further enhance the outcomes of kidney transplantation. However, studies to identify suitable interventions are lacking. Interesting factors to be influenced could be, for example, respiratory symptoms and support for professional reintegration.

CONCLUSION

Future studies should focus on the identification of adequate interventions to further improve HRQoL in kidney transplant recipients.

Multivariable Predictors of Poorer Renal Function Among 1119 Deceased Donor Kidney Transplant Recipients During the First Year Post-Transplant, With a Particular Focus on the Influence of Individual KDRI Components and Donor AKI

Given our desire to reduce kidney transplant waiting times by utilizing more difficult-to-place ("higher-risk") DD kidneys, we wanted to better understand post-transplant renal function among 1119 adult DD recipients consecutively transplanted during 2016-2019. Stepwise linear regression of eGFR (CKD-EPI formula) at 3-, 6-, and 12-months post-transplant (considered as biomarkers for longer-term outcomes), respectively, was performed to determine the significant multivariable baseline predictors, using a type I error ≤ 0.01 to avoid spurious/weak associations. Three unfavorable characteristics were selected as highly significant in all three models: Older DonorAge (yr) (p < 0.000001), Longer StaticColdStorage Time (hr) (p < 0.000001), and Higher RecipientBMI (p ≤ 0.00003). Other significantly unfavorable characteristics included: Shorter DonorHeight (cm) (p ≤ 0.00001), Higher Natural Logarithm {Initial DonorCreatinine} (p ≤ 0.001), Longer MachinePerfusion Time (p ≤ 0.003), Greater DR Mismatches (p = 0.01), DonorHypertension (p ≤ 0.004), Recipient HIV+ (p ≤ 0.006), DCD Kidney (p = 0.002), Cerebrovascular DonorDeath (p = 0.01), and DonorDiabetes (p = 0.01). Variables not selected into any model included DonorAKI Stage (p ≥ 0.24), Any DonorAKI (p ≥ 0.04), and five KDRI components: two DonorAge splines at 18 years (p ≥ 0.52) and 50 years (p ≥ 0.28), BlackDonor (p ≥ 0.08), DonorHCV+ (p ≥ 0.06), and DonorWeight spline at 80 kg (p ≥ 0.03), indicating that DonorAKI and the weaker KDRI components have little, if any, prognostic impact on renal function during the first 12 months post-transplant. Additionally, biochemical determinations with skewed distributions such as DonorCreatinine are more accurately represented by natural logarithmic transformed values. In conclusion, one practical takeaway is that donor AKI may be ignored when evaluating DD risk.

Waitlist management for inactive status kidney transplant patients: a scoping review

Over 808 000 people live with end-stage renal disease (ESRD) in the United States. Kidney transplantation (KT) is the preferred treatment for ESRD, offering patients the best chance for long-term survival and improved quality of life compared to prolonged dependence on dialysis. There are nearly 90 000 people on the waitlist for transplant, but nearly half (47%) of patients on the KT waitlist are classified as inactive. Patients on the inactive KT waitlist have an elevated risk of post-transplant mortality and adverse outcomes. Reducing the time patients remain on the inactive KT waitlist is critical for transplant centers. Managing the waitlist for more than 250 kidney transplant programs in the US is resource and personnel intensive, and there are no best practice guidelines. Using the Johns Hopkins Nursing for Evidence-Based Practice Model as a guide, this scoping review examines the available literature on best practices for waitlist management for inactive status adult kidney transplant patients. Two themes were identified: (1) recognizing barriers to reactivation and (2) improved communication. The persistent challenges associated with inactive patients on the KT waitlist underscore the need for targeted interventions and a holistic, patient-centric approach. This review contributes to the limited literature on waitlist management for inactive KT patients and gives insights for future research, policy initiatives, and strategies to optimize the efficiency and equity of managing inactive status KT patients.

The Early Steps to Transplant Access Registry (E-STAR) dashboard: center-specific reporting on prewaitlisting data to improve access to kidney transplantation

PURPOSE OF REVIEW

The 2022 National Academies of Sciences, Engineering, and Medicine report highlighted inequities in access to kidney transplantation and called for a comprehensive dashboard highlighting early transplant steps, yet data on steps such as referral and evaluation start are limited. Addressing this gap is crucial for improving equity in access to transplantation.

RECENT FINDINGS

The Early Steps to Transplant Access Registry (E-STAR) provides a model for how prewaitlisting data can be used to inform quality improvement to drive equity in access to transplantation. E-STAR includes data from 37 transplant centers across 13 states and four regions (Southeast, New York, New England, and the Ohio River Valley), representing ∼217 000 adults with end-stage kidney disease (ESKD) treated in 4365 dialysis facilities, in addition to patients preemptively referred. Similar to the Scientific Registry of Transplant Recipients center-specific reports, the E-STAR dashboard was developed as an interactive website offering center-specific and regional insights into pretransplant access measures within and across centers with the intention to improve access to transplantation. Publicly available de-identified reports illustrate trends in referral, evaluation, and waitlisting by subgroup (e.g., race, sex, age, insurance status), while password-protected features enable transplant centers to benchmark their performance against anonymized peers.

SUMMARY

The E-STAR dashboard demonstrates how centralized, standardized data collection can support transplant centers, policymakers, community partners, and regional organizations to identify disparities, drive quality improvement, and develop interventions for the advancement of equity in transplant access. This work may inform future center-specific reports once prewaitlisting data are collected nationally.

The case for value-based care in kidney transplantation: insights into geography, growth, and financial models

PURPOSE OF REVIEW

Kidney transplantation (KT) is the preferred treatment for end-stage renal disease (ESRD), yet systemic challenges, including geographic disparities, impede equitable access. This review evaluates transplant center activity and regional disparities using recent trends and discusses the potential of value-based care (VBC) models like the proposed Increasing Organ Transplant Access (IOTA) model to address these challenges.

RECENT FINDINGS

Analysis of Organ Procurement and Transplantation Network (OPTN) data from 2021 to 2023 identified 185 of 322 transplant centers as potentially eligible for VBC inclusion. High ESRD prevalence states like Texas, California, and New York have the largest number of centers, while states like Wyoming and Vermont lack operational centers, creating access barriers. Growth in KT rates following the 2014 Kidney Allocation System (KAS) reforms has stabilized at 3-5% since 2023. Geographic disparities persist, with regions like the South Atlantic and Pacific showing high transplant activity but unmet demand relative to ESRD prevalence.

SUMMARY

The proposed IOTA model could mitigate disparities by incentivizing infrastructure investment and prioritizing equitable access. Tailored VBC strategies are essential to addressing regional needs and improving KT equity and outcomes nationwide.

Comparison of Magnetic and Conventional Double-J Stent Following Kidney Transplantation: A Randomized Controlled Trial

Background

This monocentric, randomized controlled trial aims to compare the outcomes of kidney transplant recipients with magnetic double-J (DJ) stents versus conventional DJ stents. Specifically, we assessed stent-related symptoms, procedural difficulties, pain and duration of removal, and associated costs.

Methods

A total of 30 patients were randomly assigned to receive either a magnetic DJ (mDJ) stent or a conventional, standard DJ (sDJ) stent during kidney transplantation using the Lich-Gregoir technique. Quality of life was evaluated with the USSQ 7-10 d postoperation. sDJs stents were removed cystoscopically by a urologist while mDJ stents were removed bedside by a transplant surgeon. The duration of removal and procedure-associated pain were documented. Questionnaires for physicians and patients were used to assess peri-interventional experience and issues. Additionally, costs associated with the removal of both stents were analyzed.

Results

Quality of life showed no differences between the groups. Stent removal was successful in all cases, with no differences in duration of removal (P = 0.24) or major issues. Patients reported comparable pain levels during the removal of mDJs (P = 0.55) and higher satisfaction, although this was not statistically significant (P = 0.27). Cost analysis revealed a reduction of approximately €172 with the use of mDJ.

Conclusions

The use of mDJ stents in kidney transplantation is a safe alternative associated with comparable pain during removal. Additionally, it offers cost savings and reduces the logistical burden for both patients and hospitals.

Testicular Pain After Living Kidney Donation: Results From a Multicenter Cohort Study

Background

Some men who donate a kidney have reported testicular pain after donation; however, attribution to donation is not clear as no prior studies included a comparison group of nondonors.

Objective

To examine the proportion of male donors who reported testicular pain in the years after nephrectomy compared to male nondonors with similar baseline health characteristics.

Design Participants and Setting

We enrolled 1042 living kidney donors (351 male) before nephrectomy from 17 transplant centers (12 in Canada and 5 in Australia) from 2004 to 2014. A concurrent sample of 396 nondonors (126 male) was enrolled. Follow-up occurred until November 2021.

Measurements

Donors and nondonors completed the same schedule of measurements at baseline (before nephrectomy) and follow-up. During follow-up, participants completed a questionnaire asking whether they had experienced new pain in their eyes, hands, or testicles; those who experienced pain were asked to indicate on which side of the body the pain occurred (left or right). The pain questionnaire was completed by 290 of 351 male donors (83%) and 97 of 126 male nondonors (77%) a median of 3 years after baseline (interquartile range = 2-6).

Methods

Inverse probability of treatment weighting on a propensity score was used to balance donors and nondonors on baseline characteristics. After weighting, the nondonor sample increased to a pseudo sample of 295, and most baseline characteristics were similar between donors and nondonors.

Results

At baseline, donors (n = 290) were a mean age of 49 years; 83% were employed, and 80% were married; 246 (84.8%) underwent laparoscopic surgery and 44 (15.2%) open surgery; 253 (87.2%) had a left-sided nephrectomy and 37 (12.8%) a right-sided nephrectomy. In the weighted analysis, the risk of testicular pain was significantly greater among donors than nondonors: 51/290 (17.6%) vs 7/295 (2.3%); weighted risk ratio, 7.8 (95% confidence interval [CI] = 2.7 to 22.8). Donors and nondonors did not differ statistically in terms of self-reported eye pain or hand pain. Among donors, the occurrence of testicular pain was most often unilateral (92.2%) and on the same side as the nephrectomy (90.2%). Testicular pain occurred more often in donors who had laparoscopic vs open surgery: 48/246 (19.5%) vs 3/44 (6.8%) but was similar in those who had a left-sided vs right-sided nephrectomy: 44/253 (17.4%) vs 7/37 (18.9%).

Limitations

Participants recalled their symptoms several years after baseline, and we did not assess the timing, severity, or duration of pain or any treatments received for the pain.

Conclusion

Unilateral testicular pain on the same side of a nephrectomy is a potential complication of living kidney donation that warrants further investigation.

Examining kidney donation in Nigeria: a mixed methods study of family members' knowledge, perceptions, information needs and decision-making

BACKGROUND

A major challenge of transplantation is the unavailability of organs. For a successful transplantation process, awareness and negative attitudes among potential donors need to be sought for and addressed. Our objective was to examine the knowledge, perception and information needs of family members of patients with chronic kidney disease (CKD) in Nigeria and factors associated with their likelihood to decide to donate a kidney.

METHODS

This was a convergent parallel mixed method study that obtained information from family members of patients with CKD in Nigeria. Ordinal logistic regression was used to determine factors associated with the likelihood of donation. Thematic analysis was used for the qualitative analysis.

RESULTS

Three hundred and six respondents with a mean age of 41.2 ± 12.9 years participated in the quantitative survey. About 30% of participants were not familiar with the concept of kidney donation; 63% had never sought information about kidney donation; about 75% felt inadequately informed about the risks, benefits, and requirements of kidney donation. About 26% of participants were unlikely to consider donating a kidney to a family member with CKD. The majority expressed medical risk (47%) as their primary concern with donation. The age group of respondents (OR 0.48, 95% CI 0.239-0.967, P = 0.04), parent/child relationship, (OR 2.42, 95%CI 1.198-4.886, P = 0.01), awareness of the suitable medical factors for donation (OR 2.07, 95%CI 1.127-3.796, P = 0.02), and provision of support or counsel to donors (OR 3.89, 95%CI 1.576-9.638, P = 0.003), were independently associated with decisions to donate. The qualitative analysis identified personal, socio-cultural, religious and psychological factors that could influence willingness to donate.

CONCLUSION

This study identified factors that influenced donations and brought to the fore the need to adequately educate and provide support for potential kidney donors.

CLINICAL TRIAL NUMBER

Not applicable.

Clinical Outcomes and Healthcare Utilization in Patients Receiving Maintenance Dialysis After the Onset of the COVID-19 Pandemic in Ontario, Canada

Background

The impact of the COVID-19 pandemic on clinical outcomes and healthcare utilization in patients receiving maintenance dialysis is unclear.

Objective

To compare the rates of clinical outcomes and healthcare utilization in patients receiving maintenance dialysis (in-center and home modalities) before and during the COVID-19 pandemic.

Design

Population-based, repeated cross-sectional study.

Setting

Linked administrative healthcare databases from Ontario, Canada.

Patients

Adults receiving maintenance dialysis from March 15, 2017, to March 14, 2020 (pre-COVID-19 pandemic period) and from March 15, 2020, to March 14, 2023 (COVID-19 pandemic period).

Measurements

Our primary outcome was all-cause mortality. Our secondary outcomes included non-COVID-19-related mortality, all-cause hospitalizations (excluding elective surgeries), emergency room visits, intensive care unit admissions, and hospital admissions with mechanical ventilation. We also examined cardiovascular-related hospitalizations, kidney-related outcomes, and ambulatory visits.

Methods

We used Poisson generalized estimating equations to model pre-COVID outcome trends and used these to predict post-COVID outcomes and to estimate the relative change (i.e., the ratio of the observed to the expected rate).

Results

In 31 900 individuals receiving maintenance dialysis during the study period, the crude incidence rate (per 1000 person-years) of all-cause mortality was 165.0 in the pre-COVID-19 period, compared to 173.2 during the first year of the pandemic and 171.7 during the first 36 months of the pandemic. After adjustment, there was a statistically significant increase in all-cause mortality in 14 out of the 36 months of the COVID-19 period compared to the pre-COVID-19 period, with 494 recorded COVID-19-related deaths. However, when examining the overall all-cause mortality across the months, the adjusted relative rate (aRR) comparing the observed to expected all-cause mortality rate was not statistically significant in the first year of the pandemic (1.08, 95% CI: 1.00, 1.16) and the first 36 months of the pandemic (1.08, 95% CI: 0.99, 1.18) compared to the pre-pandemic period. The crude incidence rate of non-COVID-19-related mortality was 165.0 in the pre-COVID-19 period, compared to 163.3 during the first year of the pandemic and 157.7 during the first 36 months. After adjustment, there was no substantial change in the rate of non-COVID-19-related deaths in the first year of the pandemic (aRR 1.01, 95% CI: 0.94, 1.09), but there was a substantial decrease in all-cause hospitalization, with an aRR of 0.92 (95% CI: 0.88, 0.97), and a substantial decrease in emergency room visits and intensive care unit admissions; findings were consistent 36 months into the pandemic.

Limitations

External generalizability to other jurisdictions may be limited, with each region experiencing different COVID-19 rates and implementing different mitigation strategies.

Conclusions

In the maintenance dialysis population, all-cause mortality was significantly higher during several months of the pandemic; however, the overall rate of all-cause mortality was not substantially higher than expected in the first 36 months of the COVID-19 pandemic. There was no substantial increase in non-COVID-19-related mortality despite a substantial decrease in acute healthcare utilization. Ongoing monitoring of the dialysis population will offer further insights into the long-term effects of the pandemic.

Outcomes of Kidney Transplant Recipients Versus Non-Recipients in the Intensive Care Unit: A Systematic Review and Meta-Analysis

Background/Objectives: With the growing population of kidney transplant recipients (KTRs) in intensive care units (ICUs), understanding their prognostic outcomes is critical. As conflicting findings exist, we aim to systematically evaluate and meta-analyze ICU outcomes in kidney transplant recipients compared to non-recipients. Methods: We conducted a comprehensive search of the PubMed, Embase, and Cochrane databases, from inception through 23 December 2024, to identify relevant studies comparing the outcomes of KTRs and non-transplant ICU patients. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated for dichotomous outcomes, and weighted mean differences (WMDs) were calculated for continuous outcomes. The risk of bias was assessed using the ROBINS-I V2 tool. The study protocol was registered in the International Prospective Register of Systematic Reviews (CRD42024595104). Results: Seven studies, including 12,062 patients, were analyzed. Demographics, including age and sex, were comparable across groups. No statistically significant associations were found for overall mortality (OR: 1.82, 95% CI: 0.79 to 4.16), ICU mortality (OR: 1.06, 95% CI: 0.45 to 2.48), or 28/30-day mortality (OR: 2.06, 95% CI: 0.30 to 14.10) in KTRs, though there was a trend suggesting a potential increase in the odds of overall mortality. KTRs tended to have longer ICU stays (WMD: +1.96 days, 95% CI: 0.81-3.11) and higher Sequential Organ Failure Assessment (SOFA) scores (WMD: +0.79, 95% CI: -0.78-2.36), but these findings did not reach statistical significance. One study reported higher 1-year and 5-year mortality for KTRs. Sensitivity analyses revealed one influential study. Begg's test for overall mortality suggested non-significant publication bias (p = 1.0). Conclusions: KTRs in ICUs are at significantly higher risk for long-term mortality, emphasizing the need for tailored critical care strategies and long-term management. Future research should focus on standardizing methodologies, reducing heterogeneity, and addressing gaps in data to improve evidence-based care for this vulnerable population.

Defining Referral for a Kidney Transplant Evaluation as a Quality Indicator: A Population-Based Cohort Study

Background

Quality indicators are required to identify gaps in care and to improve equitable access to kidney transplants. Referral to a transplant center for an evaluation is the first step toward receiving a kidney transplant, yet widespread reporting on this metric is lacking.

Objective

The objective was to use administrative health care databases to examine multiple ways to define referral for a kidney transplant evaluation by varying clinical inclusion criteria, definitions for end of follow-up, and statistical methodologies.

Design

This is a population-based cohort study.

Setting

This study linked administrative health care databases in Ontario, Canada.

Patients

Adults from Ontario, Canada, with advanced chronic kidney disease (CKD) between April 1, 2017, and March 31, 2018.

Measurements

The primary outcome was the 1-year cumulative incidence of kidney transplant referral.

Methods

We created several patient cohort definitions, varying patient transplant eligibility by health status (eg, whether patients had a recorded contraindication to transplant). We presented results by advanced CKD status (ie, patients approaching the need for dialysis vs receiving maintenance dialysis) and by method of cohort entry (ie, incident only vs prevalent and incident patients combined), resulting in 12 unique cohorts.

Results

Sample size varied substantially from 414 to 4128 depending on the patient cohort definition, with the largest reduction in cohort size occurring when we restricted to a "healthy" (eg, no evidence of cardiovascular disease) group of patients. The 1-year cumulative incidence of transplant referral varied widely across cohorts. For example, in the incident maintenance dialysis population, the cumulative incidence varied more than 2-fold from 16.3% (95% confidence interval [CI] = 15.0%-17.7%) using our most inclusive cohort definition to 40.0% (95% CI = 36.0%-44.5%) using our most restrictive "healthy" cohort of patients.

Limitations

Administrative data may have misclassified individuals' eligibility for kidney transplant.

Conclusions

These results can be used by jurisdictions to measure transplant referral, a necessary step in kidney transplantation that is not equitable for all patients. Adoption of these indicators should drive quality improvement efforts that increase the number of patients referred for transplantation and ensure equitable access for all patient groups.

Forty years of kidney transplantation: Insights into malignancies at a single center in Latin America

BACKGROUND

Kidney transplantation is the optimal therapy for end-stage kidney disease (ESKD), but lifelong immunosuppression increases malignancy risk, a major cause of mortality in transplant recipients. This study evaluates post-transplant malignancies in a kidney transplant cohort.

METHODS

We conducted a retrospective analysis of 375 kidney transplant recipients at Hospital Las Higueras, Talcahuano (January 1981-July 2024). Demographics, clinical characteristics, and malignancy data were extracted from medical records.

RESULTS

Of 375 patients, 33 (8.8 %) developed malignancies, with 27 % experiencing multiple cancers. While the mean age at transplantation was 51.5 years, the mean age of those developing a malignancy was 60.4 years. Non-melanoma skin cancers were most common (55.1 %), followed by solid organ cancers (26.5 %), chronic kidney disease (CKD)-related cancers (8.2 %), and hematologic malignancies (8.2 %). The mean time to malignancy onset was 106 months post-transplant. Cancer-related mortality was 30 %.

CONCLUSION

The high incidence of malignancies, particularly skin cancers, highlights the need for regular clinical and dermatologic surveillance in transplant recipients. Optimizing immunosuppression to balance rejection prevention and cancer risk, along with comprehensive cancer screening, is essential for improving long-term outcomes.

Global transplantation: Lessons from organ transplantation organizations worldwide

Although national transplant organizations share common visions and goals, the creation of a unified global organization remains impractical. Differences in ethnicity, culture, religion, and education shape local practices and infrastructure, making the establishment of a single global entity unfeasible. Even with these social disparities aside, logistical factors such as time and distance between organ procurement and transplantation sites pose significant challenges. While technological advancements have extended organ preservation times, they have yet to support the demands of transcontinental transplantations effectively. This review presents a comparative analysis of the structures, operational frameworks, policies, and legislation governing various transplant organizations around the world. Key differences pertain to the administration of these organizations, trends in organ donation, and organ allocation policies, which reflect the financial, cultural, and religious diversity across different regions. While a global transplant organization may be out of reach, agreeing on best practices for the benefit of patients is essential.

Process Evaluation Alongside a Cluster-Randomized Trial of a Multicomponent Intervention Designed to Improve Patient Access to Kidney Transplantation

Background

In a cluster-randomized trial, we learned that a novel multicomponent intervention designed to improve access to kidney transplantation did not significantly increase the rate of completed steps toward receiving a kidney transplant. Alongside the trial, we conducted a process evaluation to help interpret our findings.

Objective

To determine whether the intervention addressed targeted barriers to transplant and whether the implementation occurred as planned.

Design

Mixed-methods process evaluation informed by implementation science theories.

Setting

Chronic kidney disease (CKD) programs in Ontario, Canada. These programs, providing care to patients with advanced CKD, participated in the trial from November 1, 2017 to December 31, 2021 (either in the intervention or usual care group).

Participants

Health care providers (eg, nurses, managers) at Ontario's 27 CKD programs.

Methods

We conducted surveys (n = 114/162 [70.4%]) and semi-structured interviews (n = 17/26 [65.4%]) with providers in CKD programs in Ontario, Canada. In both the intervention-group and control-group surveys, using the Theoretical Domains Framework, we assessed perceived barriers to transplant and how barriers changed throughout the trial period. In the intervention-group surveys and interviews, using the normalization process theory, we assessed the extent to which the intervention was embedded into daily routines. In the intervention-group surveys, and by completing an implementation checklist, we assessed fidelity of implementation.

Results

Perceived barriers to transplant did not substantially differ between providers in the intervention and usual care groups, and both groups reported disagreeing or feeling neutral that the targeted barriers impeded transplant access. Intervention-group providers reported that intervention activities were becoming a regular part of their work and that they engaged with its components. However, they also felt the intervention was complex and described needing more resources, a better execution plan, and more buy-in from frontline staff. Fidelity was high for administrative support, quality improvement teams, delivery of educational resources, and patient peer support. The use of performance reports was low.

Conclusions

We identified several possible reasons why the intervention was unsuccessful. Improving access to kidney transplantation remains a high priority for health care systems. We will continue to foster a quality improvement culture, and our results will guide future interventions.

Limitations

Two of the 13 intervention-group CKD programs did not participate in this evaluation.

Trial Registration

ClinicalTrials.gov Identifier: NCT03329521.

Comparing surgical outcomes between robot-assisted laparoscopic and open partial nephrectomy for allograft kidney tumors: a retrospective, single-center study

BACKGROUND

Kidney transplantation is considered the best long-term option for patients with end-stage renal disease; however, immunosuppression increases the risk of developing malignancies. Approximately 0.2-0.5% of kidney transplant recipients experience renal cell carcinoma (RCC) in their allografts. Recently, nephron-sparing surgery has become widely accepted because of its favorable survival outcomes and low risk of recurrence.

METHODS

In this study, we retrospectively evaluated the peri- and postoperative outcomes of robot-assisted partial nephrectomy (RAPN) and open partial nephrectomy (OPN) for allograft RCC, analyzing five and six patients who underwent OPN and RAPN, respectively, from 1998 to 2023.

RESULTS

The estimated blood loss was significantly lower in the RAPN group than in the OPN group (6.5 mL [interquartile range (IQR): 1-15] vs. 350 mL [IQR: 139-560], P = 0.006), whereas the operative and renal arterial clamping times were similar. Additionally, the perioperative complication rate and severity were lower in the RAPN group, resulting in a significantly shorter postoperative hospital stay than the OPN group (3 days [IQR: 2-5] vs. 10 days [IQR: 8-12], P = 0.01). Postoperative renal function and oncological outcomes were similar between the two groups.

CONCLUSIONS

RAPN for allograft RCC demonstrated advantages in terms of estimated blood loss and postoperative hospital stay compared with OPN, even though the patients' backgrounds were not adjusted. Therefore, RAPN may be a viable option for managing T1 allograft tumors.

Decreasing efficiency in deceased donor kidney offer notifications under the new distance-based kidney allocation system

Organ Procurement Organizations (OPOs) recover deceased donor kidneys and place them with matched recipients according to ranked match runs of patients, but offer notification practices differ across the OPOs and have changed following updates to allocation policy (kidney allocation system 250 [KAS250]). This national registry study used batch notification data to quantify time spent on kidney allocation and identify variations in batch notification practices across OPOs before and after the KAS250 allocation system era. Overall allocation time between the first and last offer notifications increased from a median of 1 to 7 hours under the KAS250 allocation system. For match runs of unplaced kidneys, allocation time increased from a median of 18 to 28 hours. Out-of-sequence (OOS) allocation, used by OPOs to limit nonutilization due to excess cold ischemia time, more than doubled in frequency between 2018 and 2022, with median time from first offer to initiation of OOS varying across OPOs from 0 to 47 hours. Increasing rates of organ nonutilization and the observed allocation practice differences based on organ quality demonstrate the urgent need for new approaches to achieve more efficient placement of hard-to-place kidneys. Data-driven approaches to optimize kidney allocation efforts will help ensure fairness in a system that currently allows for wide practice variation and frequent OOS allocation.

"They Know You Better Than the Transplant Team": An Interpretive Description Study Exploring the Perspectives of Living Kidney Donors About Care Received From Family Physicians

Background

Given the significant benefits of living donor kidney transplantation, the nephrology and transplant communities are augmenting efforts to increase living kidney donation. However, prior living kidney donors (LKDs) report suboptimal experiences and unmet care needs. The LKDs are healthy, and the vast majority have good outcomes post-donation. Thus, in clinical practice, their care is primarily assumed by practitioners, such as family physicians (FPs).

Objective

This study aimed to better understand the integration of primary care in LKDs' donation trajectory from the point of view of the latter. Our specific research questions were: (1) How do LKDs perceive the role of FPs currently integrated into the donation trajectory? (2) What are their needs and expectations from their FPs?

Design

An interpretive description methodology.

Setting and Participants

Canadian LKDs who donated a kidney prior to 2020.

Methods

Qualitative interviews and inductive thematic analysis.

Results

In our sample of 49 LKDs who donated between 2007 and 2020, 61.2% were women and 87.8% were white. Also, 87.8% and 83.7% were attached to an FP pre- and post-donation (1 by a nurse practitioner) with 16.3% reporting no regular FP post-donation. Although participants provided varying accounts, an overwhelming majority described challenges with timely access to needed care; lack of cohesive continuity of care; variability in the services offered by FPs; and challenges with coordination of care between providers. Many reported poor coordination and communication between FPs and donor teams. Most articulated the desire to see an expanded role for FPs. This included improvements in knowledge regarding living donor care, information and care brokerage, continuous integrative care, and mental and emotional support.

Limitations

Limited transferability of our findings to other countries with variable payment structures.

Conclusions

Our work suggests that improving LKD care requires developing care pathways that facilitate donor transition and care coordination between donor teams and primary care practitioners. Given the challenges being faced by primary care in Canada, we believe that pragmatic strategies to better support primary care practitioners and a stronger integration of primary care with the living kidney donation process are essential. In addition, strategies to better support the mental health of LKDs are also needed. The LKDs provide a valuable gift to our health systems and to patients with kidney failure. It is our responsibility to optimize their experiences and improve their care.

A comparative study of clinical outcomes and risk factors of tuberculosis in kidney transplant recipients from deceased donors

OBJECTIVE

To investigate the clinical characteristics, diagnosis and treatment of tuberculosis infection after deceased donor kidney transplantation and to analyze the risk factors and prognosis of tuberculosis infection through a paired case-control study.

METHODS

This study investigated 31 kidney transplant recipients who developed tuberculosis among 2185 total recipients during 2012-2021. We employed a 1:1 paired case-control design, utilizing 31 patients who received kidneys from the same donor as the controls. The study analyzed clinical presentation, diagnosis, treatment, risk factors, and prognosis.

RESULTS

This study identified a 1.4% incidence of tuberculosis (TB) infection (31/2185) in kidney transplant recipients. The median onset was 10.8 months post-transplant (range: 5-24 months), with 51.6% occurring within the first year. Anti-TB therapy achieved cure in 30 patients, but one died and three experienced kidney transplant dysfunctions. While overall patient survival was not statistically different between groups, kidney graft survival was significantly lower in the TB group (p = 0.042). While kidney function was initially similar, the TB group experienced significant declines in creatinine and GFR at 3, 6, and 12 months post-treatment (p < 0.05). Multivariate analysis identified diabetes mellitus (p = 0.005) and hepatitis (p = 0.027) as independent risk factors for post-transplant TB infection.

CONCLUSION

Over half of the tuberculosis cases (51.6%) occurred within the first year post-transplant, highlighting the need for heightened vigilance during this early period. While standard anti-TB therapy achieved good overall patient survival, it takes a toll on kidney function which underscores the importance of close kidney function monitoring and delicate immunosuppressant management during TB treatment. Diabetes mellitus and hepatitis were identified as independent risk factors for post-transplant TB infection. Prophylaxis measures should be considered for these high-risk patients during early time post-transplant.

Access to Transplant for African American and Latino Patients Under the 2014 US Kidney Allocation System

BACKGROUND

Kidney transplant offers better outcomes and reduced costs compared with chronic dialysis. However, racial and ethnic disparities in access to kidney transplant persist despite efforts to expand access to transplant and improve the equity of deceased donor allocation. Our objective was to evaluate after listing the association of race and ethnicity with access to deceased donor kidney transplant (DDKT) after changes to the allocation system in 2014.

METHODS

This retrospective study evaluated access to DDKT after listing since the implementation of the 2014 kidney allocation system. Waitlist status and transplant outcomes were ascertained from data from the Scientific Registry of Transplant Recipients. Our analysis included every adult kidney transplant candidate on the waiting list in the US from January 1, 2015, through June 30, 2023.

RESULTS

A total of 290 763 candidates were on the waiting list for DDKT during the study period. Of these, 36.4% of candidates were African American and 22.2% were Latino. Compared with White non-Latino patients, access to DDKT after listing was reduced for African American (unadjusted hazard ratio [HR], 0.93; 95% confidence interval [CI], 0.92-0.94) and Latino individuals (unadjusted HR, 0.88; 95% CI, 0.87-0.90). After controlling for demographic and clinical factors, these differences in access to transplant widened substantially for African American (HR, 0.78; 95% CI, 0.77-0.80) and Latino patients (HR, 0.73; 95% CI, 0.72-0.74).

CONCLUSIONS

African American and Latino patients had reduced access to DDKT after listing. More effective approaches to improving access for African American and Latino individuals after listing are needed.

Kidney Transplant Wait Times Under Waiting List Expansion Scenarios

Importance

Kidney transplantation offers survival benefits and superior quality of life compared with maintenance dialysis for patients with end-stage kidney disease (ESKD), but it is limited to approximately 25 000 patients annually in the United States. Expanding access to transplant could be accomplished by allowing more patients to join the waiting list or by increasing organ supply.

Objective

To estimate how these interventions could affect transplant wait times.

Design, Setting, and Participants

This decision-analytic study used a Markov model with a simulated cohort of transplant-eligible US patients over 10 years (2022-2032).

Exposures

Three expansion strategies: waiting list expansion alone, waiting list expansion with deceased-donor transplant (DDT) expansion, and waiting list expansion with living-donor transplant (LDT) expansion. Relative 10%, 25%, 50%, and 100% expansions of the current deceased-donor organ supply and 25%, 50%, 100%, and 200% expansions of current living donation rates were simulated, modeling 2 degrees of waiting list expansion (10% and 50%) for each strategy.

Main Outcomes and Measures

Median wait time to kidney transplant using Kaplan-Meier survival analysis.

Results

There were a total of 662 190 transplant-eligible patients in the simulated cohort, with a mean (SD) age of 58.7 (14.7) years; 327 126 (49%) female individuals; and 269 082 (41%) Black, 163 028 (25%) Hispanic, 233 739 (35%) non-Hispanic White, and 78 496 (12%) Asian individuals and individuals with another race or ethnicity. Under the baseline strategy, median (IQR) wait time was 32.8 (13.1-66.4) months and increased to 36.8 (14.7-74.7) months and 52.6 (21.0-107.9) months for 10% and 50% waiting list expansion alone. DDT and LDT expansion strategies added 1911 to 20 035 organs. For 10% waiting list expansion, median (IQR) wait times ranged from 23.7 (9.3-47.8) months to 34.5 (13.9-74.7) months. For 50% waiting list expansion, median (IQR) wait times ranged from 34.2 (13.6-69.4) months to 49.4 (19.7-101.0) months.

Conclusions and Relevance

In this decision-analytic model, expansion strategies without additional organ supply increased the median time to kidney transplant by nearly 2 years; 10% waiting list expansion required at least 2850 additional organs to shorten wait times. However, 50% waiting list expansion required at least 11 000 additional organs to approximate current wait times. Reduction in the deceased-donor organ nonuse rate alone is unlikely to meet the shortfall. Systems-level efforts to significantly increase deceased and living donation should be prioritized alongside increased access to the transplant waiting list.

Favorable Living Donor Kidney Transplantation Outcomes within a National Kidney Exchange Program: A Propensity Score-Matching Analysis

Key Points

KEP recipients have comparable long-term graft survival to direct living donor kidney transplantation recipients, which underscores the need to prioritize KEP over other's therapies. Our outcomes can be achieved regardless of whether the donor travels or the graft is transported, offering flexibility in program implementation.

Background

KEPs (kidney exchange programs) facilitate living donor kidney transplantations (LDKTs) for patients with incompatible donors, who are typically at higher risk than non-KEP patients because of higher sensitization and longer dialysis vintage. We conducted a comparative analysis of graft outcomes and risk factors for both KEP and non-KEP living donor kidney transplants.

Methods

All LDKTs performed in The Netherlands between 2004 and 2021 were included. The primary outcome measures were 1-, 5-, and 10-year death-censored graft survival. The secondary outcome measures were delayed graft function, graft function, rejection rates, and patient survival. We used a propensity score–matching model to account for differences at baseline.

Results

Of 7536 LDKTs, 694 (9%) were transplanted through the KEP. Ten-year graft survival was similar for KEP (0.916; 95% confidence interval, 0.894 to 0.939) and non-KEP (0.919; 0.912 to 0.926, P = 0.82). We found significant differences in 5-year rejection (12% versus 7%) and 5-year patient survival (KEP: 84%, non-KEP: 90%), which was nonsignificant after propensity score matching. Significant risk factors of lower graft survival included high donor age, retransplantations, extended dialysis vintage, higher panel reactive antibodies, and nephrotic syndrome as the cause of ESKD.

Conclusions

Transplantation through KEP offers a viable alternative for patients lacking compatible donors, avoiding specific and invasive pre- and post-transplant treatments. KEP's similar survival rate to non-KEPs suggests prioritizing KEP LDKTs over deceased donor kidney transplantation, desensitization, and dialysis. However, clinicians should consider the identified risk factors when planning and managing pre- and post-transplant care to enhance patient outcomes. Thus, we advocate for the broad adoption of KEP and establishment in regions lacking such programs, alongside initiation and expansion of international collaborations.

The impact of donor hepatitis B virus infection on transplant outcomes in deceased donor kidney transplantation recipients

BACKGROUND

The use of hepatitis B virus (HBV)-positive donor kidneys to expand the donor pool has been implemented, but limited evidence exists regarding their impact on transplant outcomes. This study aimed to investigate the effects of donor HBV infection on transplant outcomes.

METHODS

Donor and recipient data between 2015 and 2021 were collected. A total of 743 kidney transplant cases were screened, including 94 donor hepatitis B surface antigen (HBsAg)+/recipient HBsAg- (D+R-) and 649 donor HBsAg-/recipient HBsAg- (D-R-) cases. The analysis endpoints included recipient HBV infection, delayed graft function (DGF), peak estimated glomerular filtration rate (eGFR) within 12 months, recipient survival, and death-censored graft survival (DCGS).

RESULTS

The D+R- group had a significantly higher risk of HBV infection compared to the D-R- group (6/72 vs. 3/231; relative risk, 6.4; p = 0.007). The risk of HBV transmission decreased significantly with increasing hepatitis B surface antibody (HBsAb) titer (p for trend = 0.003). Furthermore, the D+R- group did not exhibit an increased risk of DGF compared to the D-R- group (odds ratio, 0.70; p = 0.51) in the multivariable mixed model. Both groups had similar peak eGFR within 12 months (β = 1.01, p = 0.71), and this had no impact on patient survival (hazard ratio [HR], 0.36; p = 0.10) and DCGS (HR, 0.79, p = 0.59) in the shared-frailty Cox model.

CONCLUSION

The use of HBsAg-positive donor kidneys appears relatively safe for HBV-immunized recipients in the short term. D+R- does not negatively affect graft function recovery and provides comparable posttransplant outcomes. Maintaining an HBsAb titer over 100 mIU/mL before transplantation is critical to reduce the risk of HBV transmission.

Impact of Multiple Kidney Retransplants on Post-Transplant Outcomes in the United States

BACKGROUND

Kidney retransplantation offers a valuable treatment option for patients who experience graft failure after their initial transplant. There is an increasing number of patients undergoing multiple retransplants. However, the impact of multiple kidney retransplants on post-transplant outcomes remains unclear. This study aimed to assess the association between the number of kidney retransplants and post-transplant outcomes in kidney retransplant recipients.

METHODS

We used the Organ Procurement and Transplantation Network and United Network for Organ Sharing (OPTN/UNOS) database to identify kidney-only retransplant recipients in United States from 2010 through 2019. We categorized kidney retransplant recipients based on their number of kidney retransplant into one and two plus kidney retransplant groups. The association of one vs two plus kidney retransplants with death-censored graft failure and patient death was assessed using Cox proportional hazard analysis, and acute rejection using logistic regression analysis.

RESULTS

Of 17,433 kidney retransplant recipients included in this study, 15,821 (91%) and 1612 (9%) had one and two plus kidney retransplants, respectively. Patients with two plus kidney retransplants were younger, predominantly White, had higher panel reactive antibody (PRA), public insurance, and education, but had less history of diabetes mellitus and total HLA mismatch compared with patients with one kidney retransplant. After adjusting for potential confounders, having two plus kidney retransplants was significantly associated with increased risk of death-censored graft failure (hazard ratio [HR] = 1.20, 95% confidence interval [CI] = 1.02-1.42) and allograft rejection (odds ratio [OR] = 1.30, 95% CI = 1.09-1.54), but it was not significantly associated with patient death.

CONCLUSIONS

Patients undergoing multiple kidney retransplants face a higher risk of graft failure and rejection compared with those with a single retransplant. These findings underscore the need for tailored management and monitoring strategies to improve outcomes for patients receiving multiple kidney retransplants.

Frailty in kidney transplant recipients

Kidney transplantation is the treatment of choice even for the elderly, as it improves quality of life and life expectancy, lowering the financial burden to the health care system compared to dialysis therapy. In Japan, kidney transplant recipients have become older due to the shift in demographics. Compared to community-dwelling elderly adults, elderly kidney transplant recipients undergoing immunosuppressive therapy have a higher risk of age-related outcomes including hospital readmissions, infections, dementia, malignancies, and fractures. In frailty, patients become vulnerable to adverse events after stressors due to a lack of physiologic reserve. Although it is often associated with aging, frailty can also occur in younger individuals with certain chronic illnesses or conditions including chronic kidney disease. Limited compensatory mechanisms result in functional impairment and adverse health outcomes, such as disability, falls, decreased mobility, hospitalization, and death. Although kidney transplant recipients can restore their kidney function after transplantation, most of them still have chronic kidney disease, as well as a gradual decline in graft function as a result of chronic allograft nephropathy. Wait-listed candidates for kidney transplantation with frailty are more likely to experience wait-list removal or death. Frailty at the time of transplantation is associated with complications after kidney transplantation such as delayed graft function, longer hospital stays, rehospitalizations, immunosuppression intolerance, surgical complications, and death. Nevertheless, kidney transplantation can be a viable intervention for frailty in dialysis patients.

Comparison of Clinical Outcomes Between Two Types of Dipeptidyl Peptidase-4 Inhibitors in Posttransplant Diabetes Mellitus in Kidney Transplantation Recipients: A Nationwide Population-Based Cohort Study in Korea

BACKGROUND

Dipeptidyl peptidase-4 inhibitors (DPP-4i) are antidiabetic drugs known for their minimal side effects and limited drug interaction witih immunosuppressants, making them suitable for patients with diabetes and kidney transplant recipients. However, there is limited real-world information regarding the use of DPP-4 inhibitors in patients with post transplant diabetes mellitus (PTDM).

METHOD

We performed a retrospective observational cohort study of 13,828 kidney transplant recipients form Janary 1, 2002, through December 21, 2018, using the Korean National Health Information Database. We extracted PTDM patients, and divided the patients into 2 groups baased on whether they received DPP4-inhibitor which needs dose adjustement (group A) or not (Group B) according to estimaged glomerular filtration rate.

RESULTS

Out of 3154 patients who developed PTDM after transplantation, 738 patients prescribed DPP-4 inhibitors. Among these, 490 patients prescribed Group B DPP-4 inhibitors and 238 patients prescribed Group A DPP-4 inhibitors. Multivariate-adjusted Cox regression analysis showed that compared Group B, Group A DPP-4 inhibitors was associated with higher incidence rate of genital tract infection (hazard ratio (HR) 1.87, 95% Confidence Interval (CI) 1.18-2.99), and emergency department visit (HR 3.12, 95% CI 1.89-5.16). However, there was no significantly difference in death (any cause), admission, graft failure, infection, or hypoglycemia between the 2 groups.

CONCLUSIONS

In patients with PTDM, some kinds of DPP-4 inhibitors, which need dose adjustment according to renal function, were associated with an increased rate of emergency department visit and genital tract infection.

Combating the rising tide of kidney advocacy in Europe: the seminal role of the European Kidney Health Alliance (EKHA)

Chronic kidney disease (CKD) is one of the most prevalent and fatal chronic diseases. However, the political attention CKD receives is not proportional to its significant human, economic and ecological burden. One major reason is the lack of awareness among the general population and policymakers. As a result, investment in the therapeutic approaches to CKD have largely remained inadequate, while existing therapies did not change for decades. To respond to the lack of awareness of CKD, several European and international kidney care societies, supported by national and regional organizations, founded the European Kidney Health Alliance (EKHA) in 2007. This Alliance is a Brussels-based advocacy organization representing people with kidney diseases and the kidney care community at the European Union level, and from there, also at the country level. EKHA's aim is to ensure that every candidate for kidney care, irrespective of stage of kidney disease, receives optimal and timely treatment, which is affordable at a societal and individual level. This publication reviews the European political landscape, EKHA's history, points of focus and tools for harnessing available data into advocacy on CKD. Areas discussed include prevention and screening of CKD, its health-economic and environmental impact, and the need to facilitate kidney transplantation and home dialysis. We also examine EKHA's specific approaches to enhance kidney care, its affordability and its sustainability. The EKHA model aims at forestalling the burden of CKD and its underestimated economic and ecologic impact.

Attitudes Toward Renal Xenotransplantation in a Muslim Country: Analysis of Specific Subgroups

Renal transplantation is the optimal treatment for end-stage kidney disease, but the rising demand for organs necessitates exploring alternative graft sources, including xenotransplantation. This study evaluated attitudes toward xenotransplantation among different social groups in a Muslim country. A structured survey assessing demographics, religiosity levels, attitudes toward xenotransplantation, and the influence of religious authorities was completed by 988 participants: 376 clergy members (38.1%), 206 physicians (20.9%), 162 dialysis patients and their relatives (16.4%), and 244 individuals from other groups (24.7%). Significant sociodemographic differences were observed in gender, marital status, and education (p < 0.001). Physicians and dialysis patients/relatives were likelier to support living donor transplantation (48.5%, 67.3%), whereas clergy members often reported no opinion (44.9%). Favorable attitudes toward xenotransplantation were the highest among physicians (66%) and dialysis patients/relatives (67.3%). When the animal was specified as a pig, 73.1% of the Clergy group exhibited unfavorable attitudes. However, this group significantly changed their opinion after the favorable fatwa issued by the religious authority. Logistic regression identified male gender, lower religiosity, and higher education as predictors of favorable attitudes, with physicians and dialysis patients/relatives demonstrating the strongest associations compared to clergy. To infer, collaboration between religious and scientific authorities is essential to address concerns and emphasize the potential benefits of xenotransplantation.

The estimation of healthcare cost of kidney transplantation in Japan using large-scale administrative databases

BACKGROUND

The financial burden of kidney replacement therapy (KRT) is considerable, and detailed information on KRT costs is essential for managing these huge healthcare costs. However, cost analyses for kidney transplantation (KTx) are limited in Japan. This study aimed to report the healthcare costs of KTx recipients in Japan based on large medical receipt data.

METHODS

This cost analysis of KTx recipients using the Japan Medical Data Center Claims Database between January 2005 and August 2020 identified living donor KTx (LDKT) and deceased donor KTx (DKT) recipients. The primary outcome was the total direct healthcare costs of KTx recipients. As an exploratory analysis, we examined the factors that contributed to the increase in the costs of LDKT.

RESULTS

In total, 84 LDKT and 17 DKT recipients were included in this study. The total healthcare costs for LDKT and DKT recipients during the first year after KTx were 6,639,982 and 6,840,450 JPY/year, respectively. However, after the second year post-KTx, total healthcare costs decreased to 1,735,931 and 1,348,642 JPY/year for LDKT and DKT recipients, respectively. During the first year, inpatient costs accounted for > 70% of the total healthcare costs, whereas pharmaceutical costs accounted for more than half after the second year post-KTx. The use of everolimus and male sex were associated with higher and lower total healthcare costs in the first and subsequent years after LDKT, respectively.

CONCLUSION

Using large-scale administrative databases, this study revealed the total healthcare costs of KTx in Japan and provided valuable information for the health technology assessment of KTx.

Impact of weight change on kidney transplantation outcomes: A systematic review and meta-analysis

BACKGROUND AND AIM

Kidney transplant recipients frequently experience a wide range of metabolic complications, including weight changes, which significantly impact patient outcomes and graft function, yet the relationship between weight gain and transplant outcomes remains poorly understood. This systematic review and meta-analysis aimed to synthesise existing evidence on the influence of weight gain on patient and graft outcomes following kidney transplantation to enhance clinical practice and optimise post-transplant care strategies.

MATERIALS AND METHODS

A literature search was conducted across databases such as PubMed and Scopus for peer-reviewed studies published up to 8 August 2024. We included adult kidney transplant recipients (ages 18 years and older) with substantial and clinically relevant post-transplant weight gain and a control group without such changes, focusing on outcomes including all-cause mortality, graft survival, cardiovascular events and acute rejection.

RESULTS

The pooled analysis, which included data from 11 studies, indicated no significant association between post-transplant weight gain and the risk of all-cause mortality (hazard ratio [HR] 1.21, 95% confidence interval [CI] 0.69 to 2.10, p = 0.51; I2 = 28%), cardiovascular events (HR 0.93, 95% CI 0.43 to 2.01, p = 0.85; I2 = 32%) or acute rejection (HR 1.13, 95% CI 0.76 to 1.68, p = 0.55; I2 = 9%). However, weight gain was significantly associated with an increased risk of graft failure (HR 1.58, 95% CI 1.22 to 2.05, p < 0.001; I2 = 0%).

CONCLUSION

Substantial and clinically relevant weight gain after kidney transplant was associated with a higher risk of graft failure. Within the timeframes of study observation, risks of all-cause mortality, cardiovascular events or acute rejection were not increased by weight gain in kidney transplant recipients.

Outcomes of Living Kidney Donors Following Donor Nephrectomy in Aotearoa New Zealand

Introduction

Living donor kidney transplantation is the optimal treatment for people with kidney failure (KF). Because living donors do not derive health benefits from donation, contemporary relevant information on post donation outcomes need to inform decision-making. Studies of donor outcomes are largely restricted to donations in the USA and Europe. We studied donors over a 30-year period in Aotearoa New Zealand (NZ) to investigate short-term and long-term outcomes.

Methods

This was a retrospective observational cohort study of all living kidney donors in NZ (1988-2018). The primary outcome was the incidence of KF. Secondary outcomes were death, cardiovascular disease (CVD), and the incidence of complications within 90 days after nephrectomy. Donors were identified using multiple data sources: the NZ Blood Service, the Ministry of Health (MoH), hospital records, and the Australia and New Zealand Live Kidney Donor Registry. Outcomes were determined via data linkage with the Australia and New Zealand Dialysis and Transplant (ANZDATA) registry and the MoH. Follow-up was until December 31, 2019.

Results

A total of 1339 people donated a kidney from 1988 to 2018. During 16,272 person-years of follow-up, 5 people developed KF, an incidence of 3 per 10,000 person-years (95% confidence interval [CI]:1.3-7.4). Patient survival was 99% (98.2%-99.5%) at 10 years; 30 people died during follow-up. The incidence of CVD was 11.6 (95% CI: 7.4-19.2) per 10,000 person-years; 292 donors (22%) experienced a complication following donor nephrectomy and 69 (5%) required intervention.

Conclusion

There is a low risk of KF and other complications among living kidney donors in NZ. These findings represent important contemporary data to support decision making.

Comparison of survival outcomes in preemptive versus non-preemptive kidney transplant recipients

Background

There are conflicting results regarding survival in preemptive versus non-preemptive kidney transplant recipients. The present study aimed to estimate the risk of death in preemptive versus non-preemptive kidney transplant recipients.

Materials and Methods

In the present retrospective cohort study, all end-stage renal disease (ESRD) patients who underwent kidney transplantation between 1996 and 2021 in referral kidney transplantation centers in Isfahan province were investigated. In total, 499 patients who received dialysis before kidney transplantation (non-preemptive) and 168 patients who received no dialysis before kidney transplantation (preemptive) were included in the final analysis. Data regarding demographic and clinical variables including sex, age, body mass index (BMI), follow-up duration, immunosuppressive regimen change, kidney donor type, underlying causes of ESRD, and comorbidities before and after kidney transplantation were collected.

Results

The mean age was 55.47 ± 15.53 years in preemptive and 54.87 ± 14.69 years in non-preemptive patients (P = 0.65). Mortality rates were 24.44/1000 person-years of follow-up for preemptive and 18.25/1000 person-years of follow-up for non-preemptive patients (P = 0.013). In the crude model of Cox regression analysis, preemptive kidney transplant recipients had a significantly higher risk of mortality compared to non-preemptive kidney transplant recipients (hazard ratio [HR] = 1.59; 95% confidence interval [CI]: 1.09-2.33; P = 0.015). However, the association attenuated and became insignificant after adjustment for confounders, including age, BMI, immunosuppressive regimen change, kidney donor type, and comorbidities (HR = 1.35; 95% CI: 0.92-1.99; P = 0.12).

Conclusion

The results of the present study indicated that there is no independent association between preemptive kidney transplantation and increased risk of mortality.

Trends in Sex Disparities in Access to Kidney Transplantation: A Nationwide US Cohort Study

RATIONALE & OBJECTIVE

Women with kidney failure have reduced access to kidney transplantation compared with men. We examined trends in sex inequities in access to transplantation over time.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

2.3 million adults identified within the US Renal Data System, aged 18-79 years, who initiated kidney replacement therapy (KRT) between 1997 and 2020.

EXPOSURE

Era of KRT (1997-2000, 2001-2004, 2005-2008, 2009-2012, 2013-2016, or 2017-2020), sex (male or female).

OUTCOME

Placement onto the kidney transplant waitlist, or living-donor kidney transplant (LDKT) among all individuals initiating KRT, and deceased donor kidney transplantation (DDKT) among patients on the waitlist.

ANALYTICAL APPROACH

Multivariable cause-specific hazard models to analyze the association between sex and placement onto the waitlist, LDKT, and DDKT, by era, overall, and by categories of age, race, and cause of kidney failure.

RESULTS

Sex inequities in waitlisting became less pronounced over time. During 1997-2000 the adjusted HR comparing men with women was 0.81 (95% CI, 0.79-0.83); by 2017-2020, it had narrowed to 0.86 (95% CI, 0.85-0.87). For the outcome of LDKT, during 1997-2000, the adjusted HR comparing men with women was 0.89 (95% CI, 0.85-0.93) and by 2017-2020 had widened to 0.79 (95% CI, 0.76-0.82). For the outcome of DDKT, during 1997-2000, the adjusted HR comparing men with women was 0.92 (95% CI, 0.89-0.95) and by 2017-2020 had widened to 1.16 (95% CI, 1.14-1.19). Sex inequities in waitlisting and LDKT were greatest in women (vs men) with diabetes (27% and 37%, respectively, in 2017-2020) and older adults 60-79 years (24% and 34%, respectively, in 2017-2020), but were broadly similar across race groups.

LIMITATIONS

Residual confounding; unknown true medical eligibility for transplant.

CONCLUSIONS

Since 1997, sex inequities in waitlisting have improved but remain significant, especially for women who are older and who have diabetes-attributed kidney failure. Worsening sex inequities in LDKT among women and DDKT among waitlisted men warrant further study.

PLAIN-LANGUAGE SUMMARY

Women with kidney failure have historically had poorer access to kidney transplantation than men. The goal of the current study was to see whether access to transplantation, defined as placement onto the transplant waitlist or living (LDKT) or deceased donor kidney transplantation (DDKT), has changed over time using national registry data from>2.3 million adults initiating kidney replacement therapy in the United States. Overall, this study showed that since 1997 sex inequities in placement on the transplant waitlist have improved but remain significant, especially for women who are older or have diabetes. Unfortunately, sex inequities in LDKT favoring men have worsened over time while declines in DDKT appear to have impacted men more than women. These findings have implications for the design of policies and interventions to improve transplant equity.

Health professional experiences of kidney transplantation in regional, rural, and remote Australia

BACKGROUND

Despite the demonstrated improved patient survival and financial benefits for health services with kidney transplantation compared to dialysis, populations outside of urban areas face inequities in access and a more difficult journey to kidney transplantation than their metropolitan counterparts. This study aimed to explore the experiences of Australian kidney transplant health professionals regarding kidney transplantation processes for patients residing in regional, rural, and remote areas, with a focus on improving access to and experiences of transplantation for this patient cohort.

METHODS

Semi-structured interviews were conducted with Australian kidney transplant health professionals. Transcripts were analysed thematically.

RESULTS

Interview participants (n = 26) consisted primarily of nephrologists from transplanting centres (15%), nephrologists from regional, rural, or remote non-transplanting centres (19%), clinical pharmacists (19%), and nursing staff (19%). Six main themes were identified regarding barriers to transplantation, including ineffective communication and education, overwhelming geographical burden, fighting for equal opportunities, paucity of social support, crushing financial peril, and deprived of adequate local care. Participants also made recommendations for new or modified service delivery models to address identified barriers, including coordination of work-up testing, outreach visits for transplant assessment, increased social and financial support, and increased and earlier provision of transplant education.

CONCLUSIONS

Health professionals described patient-specific and system level barriers to kidney transplantation for regional, rural, and remote populations in Australia that could be addressed or improved by the modification of current processes or implementation of new service delivery models for provision of transplant care.

Evolving adeno-associated viruses for gene transfer to the kidney via cross-species cycling of capsid libraries

The difficulty of delivering genes to the kidney has limited the translation of genetic medicines, particularly for the more than 10% of the global population with chronic kidney disease. Here we show that new variants of adeno-associated viruses (AAVs) displaying robust and widespread transduction in the kidneys of mice, pigs and non-human-primates can be obtained by evolving capsid libraries via cross-species cycling in different kidney models. Specifically, the new variants, AAV.k13 and AAV.k20, were enriched from the libraries following sequential intravenous cycling through mouse and pig kidneys, ex vivo cycling in human organoid cultures, and ex vivo machine perfusion in isolated kidneys from rhesus macaques. The two variants transduced murine kidneys following intravenous administration, with selective tropism for proximal tubules, and led to markedly higher transgene expression than parental AAV9 vectors in proximal tubule epithelial cells within human organoid cultures and in autotransplanted pig kidneys. Following ureteral delivery, AAV.k20 efficiently transduced kidneys in pigs and macaques. The AAV.k13 and AAV.k20 variants are promising vectors for therapeutic gene-transfer applications in kidney diseases and transplantation.

Health-related quality of life in living kidney donors participating in kidney exchange programmes

Background

Kidney exchange programmes (KEPs) have revolutionized living donor kidney transplantation (LDKT) by enabling transplants for patients with HLA- or ABO-incompatible donors. However, the implications for donors participating in KEPs, particularly regarding postoperative health-related quality of life (HRQoL), are not well elucidated. This study compares the HRQoL of donors participating in KEPs with donors donating directly (non-KEPs).

Methods

The study included 724 donors, with 121 in the KEP group and 603 in the non-KEP group. Outcomes were assessed using the mental component summary (MCS), physical component summary (PCS), EQ-5D-3L, MVI-20 score, and self-rated pain level. We used a mixed-effects regression model to assess differences between KEP and non-KEP over time, accounting for repeated measures within subjects.

Results

There was a significant temporary decline in both the MCS and PCS post-donation; however, these outcomes returned to pre-donation levels after an interval of 2 months. Donors participating in the KEP had higher PCS and MCS 1-year post-donation. Comparable results were observed in the self-assessed HRQoL using the EQ-5D-3L instrument, as well as in the fatigue scores measured by the MVI-20.

Conclusions

We found that participation in KEPs does not adversely affect donors' short- or long-term mental and physical HRQoL outcomes and that LDKT donors have HRQoL of pre-donation levels soon after donation. These insights are reassuring, indicating that donors participating in KEPs can expect HRQoL comparable to those who do not. This reinforces the viability of KEPs as a safe option for expanding LDKT and findings can inform patient and donor education.

Behind the Healing: Exploring the Psychological Battles of Kidney Transplant Patients: A Qualitative Insight

Background and Aims

Kidney transplantation is widely regarded as the optimal treatment for end-stage renal disease, offering benefits like prolonged life expectancy, enhanced quality of life, and greater cost-effectiveness compared to dialysis. While dialysis imposes considerable restrictions on patients, including diminished independence, many of these challenges can be alleviated through successful transplantation. However, despite the physical advantages of kidney transplants, the psychological struggles faced by transplant recipients are often overlooked, particularly in Ethiopia. This study aimed to delve into the psychological experiences of kidney transplant patients, shedding light on the emotional and mental battles they encounter post-transplant.

Methods

This qualitative study involved kidney transplant patients at SPMMC (St. Paul's Millennium Medical College). during the study period, regardless of donor type. A total of ten participants were selected using purposive sampling. Data were collected through semi-structured, interviewer-administered questionnaires containing both closed and open-ended questions. The data were transcribed verbatim and analyzed using interpretative phenomenological analysis (IPA). The analysis focused on understanding participants' experiences and their interpretations of these experiences. Themes were identified by examining commonalities and differences in the participants' accounts, with special attention to areas of convergence and divergence.

Results

The analysis revealed both positive and negative psychological experiences among kidney transplant patients. Positive experiences included feelings of "re-birth," thankfulness, strengthened social bonds, freedom from dialysis, enhanced self-efficacy, and increased social support. Negative experiences included dependency, fear of the future, challenges with adherence to treatment, and occasional regret.

Conclusion

Life after a kidney transplant is significantly more positive and empowering compared to life on dialysis. However, psychological challenges remain, highlighting the need for ongoing psychological support to address both positive and negative aspects of the transplant experience. Future research should focus on providing continuous support, including counseling and support groups, and integrating these systems into kidney transplant care to enhance overall recovery.

Persistent Mortality Risk From Device-related Healthcare-associated Infection in Kidney Transplant Recipients Despite Multifaceted Interventions Action Calls for a Zero-tolerance Policy

Background

Although multifaceted control intervention actions (bundles) are highly effective in reducing the risk of device-related healthcare-associated infections (d-HAIs), no studies have explored their impact on the outcomes of kidney transplant recipients (KTRs) or the extent of risk reduction achievable through the bundle implementation.

Methods

Seven hundred ninety-eight prevalent KTRs admitted to the intensive care unit (ICU) requiring invasive devices were included: 449 patients from the bundle preimplementation period and 349 from the postimplementation period. The primary outcome was mortality within 90 d of ICU admission. Using Poisson regression models, the magnitude of risk reduction for d-HAIs after the bundle implementation and the impact of d-HAIs on the risk of death was estimated.

Results

The 90-d survival rate was significantly lower in patients with d-HAIs (37.7% versus 71.7%; P < 0.001). The bundle implementation reduced the risk of d-HAIs by 58% (relative risk, 0.42; P = 0.005). Despite the significant reduction in d-HAIs after the bundle implementation, d-HAIs were associated with a 2.6-fold higher risk of death (hazard ratio [HR], 2.63; P < 0.001) regardless of the study period. Additional variables associated with increased risk of death included age (HR, 1.03; P < 0.001), baseline immunosuppression (HR based on mycophenolate versus others 0.74; P = 0.02), time since transplantation (HR, 1.003; P < 0.001), platelet count at ICU admission (HR, 0.998; P < 0.001), and sepsis as the reason for ICU admission (HR, 1.67; P < 0.001).

Conclusions

The persistent risk associated with d-HAIs, despite the implementation of multifaceted control intervention actions in an ICU specialized in KTR care, underscores the need for a zero-tolerance policy toward d-HAIs.

Identifying the Views and Needs of Family Physicians on Providing Care to Living Kidney Donors: A Cross-Sectional Survey

Optimizing the long-term care and follow-up of living kidney donors (LKDs) has been challenging, and prior LKDs have reported suboptimal healthcare experiences. Long-term care of LKDs is largely undertaken by primary care practitioners such as family physicians (FPs). We conducted a cross-sectional survey of Canadian FPs (n = 151). In our sample, 21.9% of participants reported that ≥1 patient had expressed interest in becoming a LKD, and 39.9% provided care to prior LKDs. While 55.5% knew how to find information on living kidney donation, 75.5% reported that information was not available in their practice. Only a minority had formal training in living kidney donation (<5%), and self-reported knowledge was low (median = 3 [scale 1 = not strong to 10 = very strong]). Knowledge improved significantly with educational activities, resources, experience, and practice needs. Attitudes toward living kidney donation were generally favorable with 71.5% stating that FPs should be involved in post-donation care. Clinical care guidelines (78.8%) were the most desired resource, followed by clear communication and reliable contact at transplant centers. Our findings inform the transplant community of an avenue to optimize LKD care by better-supporting FPs, who provide care to LKDs. This may enhance data collection on LKD outcomes and potentially increase donation rates.

Kidney transplant outcomes of Māori and Pasifika people receiving transplantation in Australia: an Australia and New Zealand Dialysis and Transplant Registry study

BACKGROUND

The numbers of Māori and Pasifika peoples with kidney failure living in Australia are rising. However, data describing outcomes of those proceeding to transplantation are limited. This study describes clinical outcomes of Māori and Pasifika peoples who received a kidney transplant in Australia.

AIMS

This study describes clinical outcomes of Maori and Pasifika peoples who received a kidney transplant in Australia.

METHODS

A retrospective review was conducted of kidney transplant recipients aged ≥18 years receiving their first graft between 1 January 2002 and 31 December 2021, as recorded in the Australia and New Zealand Dialysis and Transplant Registry. The primary outcome was death-censored graft survival. Secondary outcomes included delayed graft function (DGF), rejection and patient survival.

RESULTS

Of 12 543 transplant recipients, mean age was 50 years and the majority identified as male sex. A total of 89 patients identified as Māori and 313 as Pasifika. Māori and Pasifika patients were more likely to have diabetic kidney disease or obesity at time of transplantation (body mass index > 30 kg/m2) and be current or former smokers compared to other ethnicities. Times to graft loss were shorter for Māori (adjusted hazard ratio (HR) 2.06, 95% confidence interval (CI) 1.36-3.11) and Pasifika (adjusted HR 1.78, 95% CI 1.39-2.029, P < 0.001) people compared to other ethnicities. The incidences of DGF were significantly higher in the Māori (30%) and Pasifika groups (28%) compared with 22% for other ethnicities (P < 0.005). Overall patient survival was comparable (Māori HR 0.93, 95% CI 0.57-1.49, P = 0.75; Pasifika HR 1.18, Cl 0.88-1.60, P = 0.26).

CONCLUSIONS

Times to graft loss for Māori and Pasifika kidney transplant patients were shorter than for other ethnicities.

Supporting equitable access to kidney transplant in remote Western Australia using continuous quality improvement

BACKGROUND

Despite an epidemic of end-stage kidney disease in the Australian Aboriginal and Torres Strait Islander population, disparities in access to kidney transplantation persist. The journey to a successful kidney transplant is long, with an initial suitability assessment required before waitlist-specific activities begin. In an Aboriginal Community Controlled renal service, we aimed to: (i) design and implement a continuous quality improvement (CQI) approach to transplant suitability assessment, (ii) provide transplant suitability assessments for all patients of the service, (iii) describe what temporary contraindications to kidney transplantation should be the focus of health service improvements, (iv) explore participant experiences with the suitability assessment process, and (v) use our findings to inform pre- and post-transplant model of care development within Kimberley Renal Services.

METHODS

Mixed methods design with file review. Transplant suitability assessment results with descriptive analysis and semi-structured interview with thematic analysis.

RESULTS

Of completed assessments, 20/66 (30%) had no contraindications and were cleared for workup with median time on dialysis prior to assessment of 2.9 years, 42/66 (64%) had temporary contraindications, and 4/66 (6%) had permanent contraindications. Eighty-five temporary contraindications were identified in 46 individuals: 17/46 had both medical and nonmedical contraindications, 5/46 had medical contraindications only, and 24/46 had nonmedical contraindications only. The most common temporary contraindications were smoking (23/46), treatment adherence (17/46), and high body mass index (11/46). Patients wanted more information on the transplant process, and interviewers noted the importance of providing information in an appropriate way. Patients wanted more support to address modifiable health risk factors to improve their chances of future transplantation.

CONCLUSIONS

In the first stages of our CQI approach to improving access to kidney transplants for Kimberley Aboriginal people, we achieved substantial catch-up in suitability assessments and a comprehensive summary of factors impacting successful waitlisting. Our results are consistent with, and build upon other work in this space, highlighting the importance of involving Aboriginal staff and patients in education and support for prospective recipients.