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Menon G, Metoyer GT, Li Y, Chen Y, Bae S, DeMarco MP, Lee BP, Loarte-Campos PC, Orandi BJ, Segev DL, McAdams-DeMarco MA. A national registry study evaluated the landscape of kidney transplantation among presumed unauthorized immigrants in the United States. Kidney Int 2025; 107:1064-1075. [PMID: 39956339 DOI: 10.1016/j.kint.2025.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2024] [Revised: 01/17/2025] [Accepted: 01/29/2025] [Indexed: 02/18/2025]
Abstract
Unauthorized immigrants and permanent residents may experience challenges in accessing kidney transplantation due to limited healthcare access, socioeconomic and cultural barriers. Understanding the United States (US) national landscape of kidney transplantation for non-citizens may inform policy changes. To evaluate this, we utilized two cohorts from the US national registry (2013-2023): 287,481 adult candidates for first transplant listing and 190,176 adult first transplant recipients. Citizenship was categorized as US citizen (reference), permanent resident, and presumed unauthorized immigrant. Negative binomial regression was used to quantify the incidence rate ratio over time by citizenship status. Cause-specific hazards models, with clustering at the state of listing/transplant, were used to calculate the adjusted hazard ratio of waitlist mortality, kidney transplant, and post-transplant outcomes (mortality/death-censored graft failure) by citizenship category. The crude proportion of presumed unauthorized immigrants listed increased over time (2013: 0.9%, 2023:1.9%). However, after accounting for case mix and waitlist size, there was no change in listing over time. Presumed unauthorized immigrants were less likely to experience waitlist mortality (adjusted Hazard Ratio 0.54, 95% Confidence Interval: 0.46-0.62), were more likely to obtain deceased donor kidney transplant (1.11: 1.05-1.18), but less likely to receive live donor (0.80: 0.71-0.90) or preemptive kidney transplant (0.52: 0.43-0.62). When stratified by insurance status, presumed unauthorized immigrants on Medicaid were less likely to receive deceased donor kidney transplants compared to their citizen counterparts; however, presumed unauthorized immigrants with private insurance or Medicare were more likely to receive deceased donor kidney transplants. Presumed unauthorized immigrants were less likely to experience post-transplant death (0.56: 0.43-0.69) and graft failure (0.69: 0.57-0.84). Residents had similar pre- and post-transplant outcomes. Despite the barriers to kidney transplantation faced by presumed unauthorized immigrants and residents in the US, better post-transplant outcomes for presumed unauthorized immigrants compared to citizens persisted, even after accounting for differences in patient characteristics.
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Affiliation(s)
- Gayathri Menon
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA
| | - Garyn T Metoyer
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA
| | - Yiting Li
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA
| | - Yusi Chen
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA
| | - Sunjae Bae
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA
| | - Mario P DeMarco
- Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Brian P Lee
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Pablo C Loarte-Campos
- Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Babak J Orandi
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA; Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Dorry L Segev
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA; Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Mara A McAdams-DeMarco
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA; Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA.
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Rashid R, Chaudhry D, Evison F, Sharif A. Mortality risk for kidney transplant candidates with diabetes: a population cohort study. Diabetologia 2024; 67:2530-2538. [PMID: 39103718 PMCID: PMC11519178 DOI: 10.1007/s00125-024-06245-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 06/14/2024] [Indexed: 08/07/2024]
Abstract
AIMS/HYPOTHESIS It is unclear whether kidney transplant candidates with diabetes have equitable transplantation opportunities or have divergent survival probabilities stratified by kidney replacement therapy. The aim of this study was to investigate these two issues using national transplant registry data in the UK. METHODS A cohort study was undertaken of prospectively collected registry data of all wait-listed people with kidney failure receiving dialysis in the UK. All people listed for their first kidney-alone transplant between 2000 and 2019 were included. Stratification was done for cause of kidney failure. Primary outcome was all-cause mortality. Time-to-death from listing was analysed using adjusted non-proportional hazard Cox regression models, with transplantation handled as a time-dependent covariate. RESULTS A total of 47,917 wait-listed people with kidney failure formed the total study cohort, of whom 6594 (13.8%) had diabetes classified as cause of kidney failure. People with kidney failure with diabetes comprised 27.6% of the cohort (n=3681/13,359) that did not proceed to transplantation vs only 8.4% (n=2913/34,558) of the cohort that received a transplant (p<0.001). Kidney transplant candidates with diabetes were more likely to be older, of male sex and of ethnic minority background compared with those without diabetes. In an adjusted analysis, compared with remaining on dialysis, any kidney transplant provided survival benefit for wait-listed kidney transplant candidates regardless of diabetes as cause of kidney failure (RR 0.26 [95% CI 0.25, 0.27], p<0.001). CONCLUSIONS/INTERPRETATION Kidney transplant candidates with diabetes have a lower chance of transplantation despite better survival after kidney transplantation vs remaining on dialysis. The reasons for this require further investigation to ensure equal transplantation opportunities.
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Affiliation(s)
- Raja Rashid
- Department of Nephrology and Transplantation, University Hospitals Birmingham, Birmingham, UK
| | - Daoud Chaudhry
- University Hospital of North Midlands, Stoke on Trent, UK
| | - Felicity Evison
- Department of Health Informatics, University Hospitals Birmingham, Birmingham, UK
| | - Adnan Sharif
- Department of Nephrology and Transplantation, University Hospitals Birmingham, Birmingham, UK.
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.
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Cluley V, Eborall H, Hull K, Quann N, Burton JO. Progressing the understanding of chronic illness and its treatment: A post-human, ethological understanding of haemodialysis. Health (London) 2024; 28:716-735. [PMID: 37706466 PMCID: PMC11323412 DOI: 10.1177/13634593231200126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
Haemodialysis is a common treatment option offered internationally for people requiring kidney replacement therapy. Research exploring haemodialysis is predominantly clinical and quantitative, and improvements to its provision and receipt tends also to be clinically focused. In recent years, however, a number of studies have sought to explore the lived experience of haemodialysis. These studies tend to use semi-structured interviews and present descriptive findings. Such findings serve to raise the profile of patient perspectives and encourage thinking beyond the clinical gaze. To progress this, we apply a post-humanism approach to the understanding of the receipt of haemodialysis. Drawing on findings from a study to explore the experience and impact of in-centre, daytime, haemodialysis we follow Fox and Alldred's ethological toolkit to provide a post-human analysis of haemodialysis. In doing so we argue that haemodialysis exists as a heterogenous and changeable assemblage of multiple and fluid, human and non-human factors that has the capacity to affect. Here we outline this post-human approach and the impact it has for understanding not just haemodialysis but also the receipt of treatment for other chronic illnesses.
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Affiliation(s)
| | | | - Katherine Hull
- University of Leicester, UK
- University Hospitals of Leicester NHS Trust, UK
| | | | - James O Burton
- University of Leicester, UK
- University Hospitals of Leicester NHS Trust, UK
- Loughborough University, UK
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Gadelkareem RA, Abdelgawad AM, Mohammed N, Zarzour MA, Khalil M, Reda A, Hammouda HM. Challenges to establishing and maintaining kidney transplantation programs in developing countries: What are the coping strategies? World J Methodol 2024; 14:91626. [PMID: 38983660 PMCID: PMC11229866 DOI: 10.5662/wjm.v14.i2.91626] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 01/31/2024] [Accepted: 03/12/2024] [Indexed: 06/13/2024] Open
Abstract
Kidney transplantation (KT) is the optimal form of renal replacement therapy for patients with end-stage renal diseases. However, this health service is not available to all patients, especially in developing countries. The deceased donor KT programs are mostly absent, and the living donor KT centers are scarce. Single-center studies presenting experiences from developing countries usually report a variety of challenges. This review addresses these challenges and the opposing strategies by reviewing the single-center experiences of developing countries. The financial challenges hamper the infrastructural and material availability, coverage of transplant costs, and qualification of medical personnel. The sociocultural challenges influence organ donation, equity of beneficence, and regular follow-up work. Low interests and motives for transplantation may result from high medicolegal responsibilities in KT practice, intense potential psychosocial burdens, complex qualification protocols, and low productivity or compensation for KT practice. Low medical literacy about KT advantages is prevalent among clinicians, patients, and the public. The inefficient organizational and regulatory oversight is translated into inefficient healthcare systems, absent national KT programs and registries, uncoordinated job descriptions and qualification protocols, uncoordinated on-site investigations with regulatory constraints, and the prevalence of commercial KT practices. These challenges resulted in noticeable differences between KT services in developed and developing countries. The coping strategies can be summarized in two main mechanisms: The first mechanism is maximizing the available resources by increasing the rates of living kidney donation, promoting the expertise of medical personnel, reducing material consumption, and supporting the establishment and maintenance of KT programs. The latter warrants the expansion of the public sector and the elimination of non-ethical KT practices. The second mechanism is recruiting external resources, including financial, experience, and training agreements.
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Affiliation(s)
- Rabea Ahmed Gadelkareem
- Department of Urology, Assiut Urology and Nephrology Hospital, Faculty of Medicine, Assiut University, Assiut 71515, Egypt
| | - Amr Mostafa Abdelgawad
- Department of Urology, Assiut Urology and Nephrology Hospital, Faculty of Medicine, Assiut University, Assiut 71515, Egypt
| | - Nasreldin Mohammed
- Department of Urology, Assiut Urology and Nephrology Hospital, Faculty of Medicine, Assiut University, Assiut 71515, Egypt
| | - Mohammed Ali Zarzour
- Department of Urology, Assiut Urology and Nephrology Hospital, Faculty of Medicine, Assiut University, Assiut 71515, Egypt
| | - Mahmoud Khalil
- Department of Urology, Assiut Urology and Nephrology Hospital, Faculty of Medicine, Assiut University, Assiut 71515, Egypt
| | - Ahmed Reda
- Department of Urology, Assiut Urology and Nephrology Hospital, Faculty of Medicine, Assiut University, Assiut 71515, Egypt
| | - Hisham Mokhtar Hammouda
- Department of Urology, Assiut Urology and Nephrology Hospital, Faculty of Medicine, Assiut University, Assiut 71515, Egypt
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Ford CG, Leyva Y, Kruger ES, Zhu Y, Croswell E, Kendall K, Puttarajapa C, Dew MA, Ng YH, Unruh ML, Myaskovsky L. Predicting Kidney Transplant Evaluation Non-attendance. J Clin Psychol Med Settings 2024; 31:153-162. [PMID: 36959431 PMCID: PMC10035980 DOI: 10.1007/s10880-023-09953-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2023] [Indexed: 03/25/2023]
Abstract
Non-attendance to kidney transplant evaluation (KTE) appointments is a barrier to optimal care for those with kidney failure. We examined the medical and socio-cultural factors that predict KTE non-attendance to identify opportunities for integrated medical teams to intervene. Patients scheduled for KTE between May, 2015 and June, 2018 completed an interview before their initial KTE appointment. The interview assessed various social determinants of health, including demographic (e.g., income), medical (e.g. co-morbidities), transplant knowledge, cultural (e.g., medical mistrust), and psychosocial (e.g., social support) factors. We used multiple logistic regression analysis to determine the strongest predictor of KTE non-attendance. Our sample (N = 1119) was 37% female, 76% non-Hispanic White, median age 59.4 years (IQR 49.2-67.5). Of note, 142 (13%) never attended an initial KTE clinic appointment. Being on dialysis predicted higher odds of KTE non-attendance (OR 1.76; p = .02; 64% of KTE attendees on dialysis vs. 77% of non-attendees on dialysis). Transplant and nephrology teams should consider working collaboratively with dialysis units to better coordinate care, (e.g., resources to attend appointment or outreach to emphasize the importance of transplant) adjusting the KTE referral and evaluation process to address access issues (e.g., using tele-health) and encouraging partnership with clinical psychologists to promote quality of life for those on dialysis.
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Affiliation(s)
- C Graham Ford
- Center for Healthcare Equity in Kidney Disease (CHEK-D), University of New Mexico Health Sciences Center, Albuquerque, USA
| | - Yuridia Leyva
- Center for Healthcare Equity in Kidney Disease (CHEK-D), University of New Mexico Health Sciences Center, Albuquerque, USA
| | - Eric S Kruger
- Department of Physical Therapy, University of New Mexico Health Sciences Center, Albuquerque, USA
| | - Yiliang Zhu
- Department of Internal Medicine, School of Medicine, University of New Mexico, Albuquerque, USA
| | - Emilee Croswell
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, USA
| | | | - Chethan Puttarajapa
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, USA
| | - Mary Amanda Dew
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, USA
| | - Yue Harn Ng
- Department of Internal Medicine, University of Washington, Seattle, USA
| | - Mark L Unruh
- Department of Internal Medicine, School of Medicine, University of New Mexico, Albuquerque, USA
| | - Larissa Myaskovsky
- Center for Healthcare Equity in Kidney Disease (CHEK-D), University of New Mexico Health Sciences Center, Albuquerque, USA.
- Department of Internal Medicine, School of Medicine, University of New Mexico, Albuquerque, USA.
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Rostaing L, Jouve T, Terrec F, Malvezzi P, Noble J. Adverse Drug Events after Kidney Transplantation. J Pers Med 2023; 13:1706. [PMID: 38138933 PMCID: PMC10744736 DOI: 10.3390/jpm13121706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 12/04/2023] [Accepted: 12/09/2023] [Indexed: 12/24/2023] Open
Abstract
Introduction: Kidney transplantation stands out as the optimal treatment for patients with end-stage kidney disease, provided they meet specific criteria for a secure outcome. With the exception of identical twin donor-recipient pairs, lifelong immunosuppression becomes imperative. Unfortunately, immunosuppressant drugs, particularly calcineurin inhibitors like tacrolimus, bring about adverse effects, including nephrotoxicity, diabetes mellitus, hypertension, infections, malignancy, leukopenia, anemia, thrombocytopenia, mouth ulcers, dyslipidemia, and wound complications. Since achieving tolerance is not feasible, patients are compelled to adhere to lifelong immunosuppressive therapies, often involving calcineurin inhibitors, alongside mycophenolic acid or mTOR inhibitors, with or without steroids. Area covered: Notably, these drugs, especially calcineurin inhibitors, possess narrow therapeutic windows, resulting in numerous drug-related side effects. This review focuses on the prevalent immunosuppressive drug-related side effects encountered in kidney transplant recipients, namely nephrotoxicity, post-transplant diabetes mellitus, leukopenia, anemia, dyslipidemia, mouth ulcers, hypertension, and viral reactivations (cytomegalovirus and BK virus). Additionally, other post-kidney-transplantation drugs such as valganciclovir may also contribute to adverse events such as leukopenia. For each side effect, we propose preventive measures and outline appropriate treatment strategies.
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Affiliation(s)
- Lionel Rostaing
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38043 Grenoble, France; (T.J.); (F.T.); (P.M.); (J.N.)
- Institute for Advanced Biosciences (IAB), INSERM U 1209, CNRS UMR 5309, Université Grenoble Alpes, 38043 Grenoble, France
- Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Thomas Jouve
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38043 Grenoble, France; (T.J.); (F.T.); (P.M.); (J.N.)
- Institute for Advanced Biosciences (IAB), INSERM U 1209, CNRS UMR 5309, Université Grenoble Alpes, 38043 Grenoble, France
| | - Florian Terrec
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38043 Grenoble, France; (T.J.); (F.T.); (P.M.); (J.N.)
| | - Paolo Malvezzi
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38043 Grenoble, France; (T.J.); (F.T.); (P.M.); (J.N.)
| | - Johan Noble
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38043 Grenoble, France; (T.J.); (F.T.); (P.M.); (J.N.)
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Rizzolo K, Cervantes L, Wilhalme H, Vasilyev A, Shen JI. Differences in Outcomes by Place of Origin among Hispanic Patients with Kidney Failure. J Am Soc Nephrol 2023; 34:2013-2023. [PMID: 37755821 PMCID: PMC10703086 DOI: 10.1681/asn.0000000000000239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 09/14/2023] [Indexed: 09/28/2023] Open
Abstract
SIGNIFICANCE STATEMENT Hispanic patients are known to have a higher risk of kidney failure and lower rates of home dialysis use and kidney transplantation than non-Hispanic White patients. However, it is unknown whether these outcomes differ within the Hispanic community, which is heterogeneous in its members' places of origins. Using United States Renal Data System data, the authors found similar adjusted rates of home dialysis use for patients originating from places outside the United States and US-born Hispanic patients, whereas the adjusted risk of mortality and likelihood of transplantation differed depending on place (country or territory) of origin. Understanding the heterogeneity in kidney disease outcomes and treatment within the Hispanic community is crucial in designing interventions and implementation strategies to ensure that Hispanic individuals with kidney failure have equitable access to care. BACKGROUND Compared with non-Hispanic White groups, Hispanic individuals have a higher risk of kidney failure yet lower rates of living donor transplantation and home dialysis. However, how home dialysis, mortality, and transplantation vary within the Hispanic community depending on patients' place of origin is unclear. METHODS We identified adult Hispanic patients from the United States Renal Data System who initiated dialysis in 2009-2017. Primary exposure was country or territory of origin (the United States, Mexico, US-Puerto Rico, and other countries). We used logistic regression to estimate differences in odds of initiating home dialysis and competing risk models to estimate subdistribution hazard ratios (SHR) of mortality and kidney transplantation. RESULTS Of 137,039 patients, 44.4% were US-born, 30.9% were from Mexico, 12.9% were from US-Puerto Rico, and 11.8% were from other countries. Home dialysis rates were higher among US-born patients, but not significantly different after adjusting for demographic, medical, socioeconomic, and facility-level factors. Adjusted mortality risk was higher for individuals from US-Puerto Rico (SHR, 1.04; 95% confidence interval [CI], 1.01 to 1.08) and lower for Mexico (SHR, 0.80; 95% CI, 0.78 to 0.81) and other countries (SHR, 0.83; 95% CI, 0.81 to 0.86) compared with US-born patients. The adjusted rate of transplantation for Mexican or US-Puerto Rican patients was similar to that of US-born patients but higher for those from other countries (SHR, 1.22; 95% CI, 1.15 to 1.30). CONCLUSIONS Hispanic people from different places of origin have similar adjusted rates of home dialysis but different adjusted rates of mortality and kidney transplantation. Further research is needed to understand the mechanisms underlying these observed differences in outcomes.
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Affiliation(s)
- Katherine Rizzolo
- Section of Nephrology, Boston University Chobanian and Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Lilia Cervantes
- Department of Medicine, University of Colorado Anschutz Campus, Denver, Colorado
| | - Holly Wilhalme
- David Geffen School of Medicine at University of California, Los Angeles, California, Los Angeles, California
| | - Arseniy Vasilyev
- David Geffen School of Medicine at University of California, Los Angeles, California, Los Angeles, California
| | - Jenny I. Shen
- David Geffen School of Medicine at University of California, Los Angeles, California, Los Angeles, California
- The Lundquist Institute at Harbor-UCLA Medical Center, Torrance, California
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Pedreros-Rosales C, Jara A, Lorca E, Mezzano S, Pecoits-Filho R, Herrera P. Unveiling the Clinical Benefits of High-Volume Hemodiafiltration: Optimizing the Removal of Medium-Weight Uremic Toxins and Beyond. Toxins (Basel) 2023; 15:531. [PMID: 37755957 PMCID: PMC10535648 DOI: 10.3390/toxins15090531] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 08/20/2023] [Accepted: 08/22/2023] [Indexed: 09/28/2023] Open
Abstract
Dialysis treatment has improved the survival of patients with kidney failure. However, the hospitalization and mortality rates remain alarmingly high, primarily due to incomplete uremic toxin elimination. High-volume hemodiafiltration (HDF) has emerged as a promising approach that significantly improves patient outcomes by effectively eliminating medium and large uremic toxins, which explains its increasing adoption, particularly in Europe and Japan. Interest in this therapy has grown following the findings of the recently published CONVINCE study, as well as the need to understand the mechanisms behind the benefits. This comprehensive review aims to enhance the scientific understanding by explaining the underlying physiological mechanisms that contribute to the positive effects of HDF in terms of short-term benefits, like hemodynamic tolerance and cardiovascular disease. Additionally, it explores the rationale behind the medium-term clinical benefits, including phosphorus removal, the modulation of inflammation and oxidative stress, anemia management, immune response modulation, nutritional effects, the mitigation of bone disorders, neuropathy relief, and amyloidosis reduction. This review also analyzes the impact of HDF on patient-reported outcomes and mortality. Considering the importance of applying personalized uremic toxin removal strategies tailored to the unique needs of each patient, high-volume HDF appears to be the most effective treatment to date for patients with renal failure. This justifies the need to prioritize its application in clinical practice, initially focusing on the groups with the greatest potential benefits and subsequently extending its use to a larger number of patients.
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Affiliation(s)
- Cristian Pedreros-Rosales
- Departamento de Medicina Interna, Facultad de Medicina, Universidad de Concepción, Concepción 4070386, Chile
- Nephrology Service, Hospital Las Higueras, Talcahuano 4270918, Chile
| | - Aquiles Jara
- Departamento de Nefrología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago 8320000, Chile
| | - Eduardo Lorca
- Departamento de Medicina Interna, Facultad de Medicina, Campus Oriente, Universidad de Chile, Santiago 7500922, Chile
| | - Sergio Mezzano
- Instituto de Medicina, Facultad de Medicina, Universidad Austral, Valdivia 5110566, Chile
| | - Roberto Pecoits-Filho
- Arbor Research Collaborative for Health, Ann Arbor, MI 48108, USA
- School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba 80215-901, Brazil
| | - Patricia Herrera
- Departamento de Medicina Interna, Facultad de Medicina, Campus Oriente, Universidad de Chile, Santiago 7500922, Chile
- Nephrology Service, Hospital del Salvador, Santiago 8320000, Chile
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Hedley JA, Kelly PJ, Wyld M, Shah K, Morton RL, Byrnes J, Rosales BM, De La Mata NL, Wyburn K, Webster AC. Cost-effectiveness of Interventions to Increase Utilization of Kidneys From Deceased Donors With Primary Brain Malignancy in an Australian Setting. Transplant Direct 2023; 9:e1474. [PMID: 37090124 PMCID: PMC10118354 DOI: 10.1097/txd.0000000000001474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 01/26/2023] [Accepted: 01/28/2023] [Indexed: 04/25/2023] Open
Abstract
Kidneys from potential deceased donors with brain cancer are often foregone due to concerns of cancer transmission risk to recipients. There may be uncertainty around donors' medical history and their absolute transmission risk or risk-averse decision-making among clinicians. However, brain cancer transmissions are rare, and prolonging waiting time for recipients is harmful. Methods We assessed the cost-effectiveness of increasing utilization of potential deceased donors with brain cancer using a Markov model simulation of 1500 patients waitlisted for a kidney transplant, based on linked transplant registry data and with a payer perspective (Australian government). We estimated costs and quality-adjusted life-years (QALYs) for three interventions: decision support for clinicians in assessing donor risk, improved cancer classification accuracy with real-time data-linkage to hospital records and cancer registries, and increased risk tolerance to allow intermediate-risk donors (up to 6.4% potential transmission risk). Results Compared with current practice, decision support provided 0.3% more donors with an average transmission risk of 2%. Real-time data-linkage provided 0.6% more donors (1.1% average transmission risk) and increasing risk tolerance (accepting intermediate-risk 6.4%) provided 2.1% more donors (4.9% average transmission risk). Interventions were dominant (improved QALYs and saved costs) in 78%, 80%, and 87% of simulations, respectively. The largest benefit was from increasing risk tolerance (mean +18.6 QALYs and AU$2.2 million [US$1.6 million] cost-savings). Conclusions Despite the additional risk of cancer transmission, accepting intermediate-risk donors with brain cancer is likely to increase the number of donor kidneys available for transplant, improve patient outcomes, and reduce overall healthcare expenditure.
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Affiliation(s)
- James A. Hedley
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
| | - Patrick J. Kelly
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
| | - Melanie Wyld
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
- Centre for Transplant and Renal Research, Westmead Hospital, New South Wales, Australia
| | - Karan Shah
- National Health and Medical Research Council Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
| | - Rachael L. Morton
- National Health and Medical Research Council Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
| | - Juliet Byrnes
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
| | - Brenda M. Rosales
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
| | - Nicole L. De La Mata
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
| | - Kate Wyburn
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
- Renal Unit, Royal Prince Alfred Hospital, New South Wales, Australia
| | - Angela C. Webster
- Collaborative Centre for Organ Donation Evidence, Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
- Centre for Transplant and Renal Research, Westmead Hospital, New South Wales, Australia
- National Health and Medical Research Council Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
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Ernst Z, Wilson A, Peña A, Love M, Moore T, Vassar M. Factors associated with health inequities in access to kidney transplantation in the USA: A scoping review. Transplant Rev (Orlando) 2023; 37:100751. [PMID: 36958131 DOI: 10.1016/j.trre.2023.100751] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 02/22/2023] [Accepted: 02/25/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND The kidney is the most needed organ for transplantation in the United States. However, demand and scarcity of this organ has caused significant inequities for historically marginalized groups. In this review, we report on the frequency of inequities in all steps of kidney transplantation from 2016 to 2022. Search criteria was based on the National Institute of Health's (NIH) 2022 list of populations who experience health inequities, which includes: race and ethnicity; sex or gender; Lesbian, Gay, Bisexual, Transgender, Queer + (LGBTQ+); underserved rural communities; education level; income; and occupation status. We outline steps for future research aimed at assessing interventions and programs to improve health outcomes. METHODS This scoping review was developed following guidelines from the Joanna Briggs Institute and PRISMA extension for scoping reviews. In July 2022, we searched Medline (via PubMed) and Ovid Embase databases to identify articles addressing inequities in access to kidney transplantation in the United States. Articles had to address at least one of the NIH's 2022 health inequity groups. RESULTS Our sample of 44 studies indicate that Black race, female sex or gender, and low socioeconomic status are negatively associated with referral, evaluation, and waitlisting for kidney transplantation. Furthermore, only two studies from our sample investigated LGBTQ+ identity since the NIH's addition of SGM in 2016 regarding access to transplantation. Lastly, we found no detectable trend in studies for the four most investigated inequity groups between 2016 and 2022. CONCLUSION Investigations in inequities for access to kidney transplantation for the two most studied groups, race/ethnicity and sex or gender, have shown no change in frequencies. Regarding race and ethnicity, continued interventions focused on educating Black patients and staff of dialysis facilities may increase transplant rates. Studies aimed at assessing effectiveness of the Kidney Paired Donation program are highly warranted due to incompatibility problems in female patients. The sparse representation for the LGBTQ+ population may be due to a lack of standardized data collection for sexual orientation. We recommend this community be engaged via surveys and further investigations.
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Affiliation(s)
- Zachary Ernst
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States of America.
| | - Andrew Wilson
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States of America
| | - Andriana Peña
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States of America
| | - Mitchell Love
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States of America
| | - Ty Moore
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States of America
| | - Matt Vassar
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States of America; Department of Psychiatry and Behavioral Sciences, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States of America.
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Chen F, Zou Y, Wang J, Huang C. Bone Marrow Mesenchymal Stem Cells (BMSCs)-Exosomes Carrying MicroRNA-965 Attenuates Allogeneic Renal Transplant Rejection Through Regulation of Janus Kinase/Signal Transducers and Activators of Transcription 3 (JAK/STAT3). J BIOMATER TISS ENG 2022. [DOI: 10.1166/jbt.2022.3081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
This study intends to evaluate the potential effect of BMSC-derived exosomes (exo) on the rejection of allogeneic kidney transplantation in a rat model. BMSCs were cultured and their exos were collected for characterization, in which the expression of miR-965 was detected by PCR. Rats
received orthotopic kidney transplantation and treated with exos or PBS followed by analysis of serum creatinine and BUN, inflammatory cell infiltration, renal fibrosis and vascular wall fibrosis by immunohistochemistry staining, JAK2/STAT3 phosphorylation by Western-blot, the inflammatory
factor level by ELISA kit, and CD4+ cells differentiation by flow cytometry. miR-965 was enriched in BMSC-derived exo. Treatment with exo ameliorated the allograft rejection, improved renal function, and reduced the histological changes of kidney. In addition, exosomal treatment decreased
the level of serum inflammatory cytokines, and altered T cell subpopulations. Meanwhile, fibrosis and neointima formation was reduced as demonstrated by related protein expression and signaling pathways was inactivated in the presence of exos. In conclusion, the miR-965 derived from BMSC-exos
mitigated the renal allograft rejection through JAK/STAT3 signaling.
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Affiliation(s)
- Fang Chen
- Department of Multi-Organ Transplant Center, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, 610072, China; Chinese Academy of Sciences Sichuan Translational Medicine Research Hospital,
Chengdu, Sichuan, 610072, China
| | - Yang Zou
- Department of Renal Department, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, 610071, China; Chinese Academy of Sciences Sichuan Translational Medicine Research Hospital, Chengdu, 610072,
China
| | - Jiansong Wang
- Department of Urology, Hunan Provincial People’s Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, Hunan, 410005, China
| | - Chuyang Huang
- Department of Urology, Shaoyang Central Hospital of Hunan, Shaoyang, Hunan, 22099, China
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Pande M, Grafals M, Rizzolo K, Pomfret E, Kendrick J. Reducing disparities in kidney transplantation for Spanish-speaking patients through creation of a dedicated center. BMC Nephrol 2022; 23:251. [PMID: 35840913 PMCID: PMC9283817 DOI: 10.1186/s12882-022-02879-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 07/04/2022] [Indexed: 11/15/2022] Open
Abstract
Introduction Hispanic Americans receive disproportionately fewer organ transplants than non-Hispanic whites. In 2018, the Hispanic Kidney Transplant Program (HKTP) was established as at the University of Colorado Hospital (UCH). The purpose of this quality improvement study was to examine the effect of this culturally sensitive program in reducing disparities in kidney transplantation. Methods We performed a mixed-methods analysis of data from 436 Spanish-speaking patients referred for transplant to UCH between 2015 and 2020. We compared outcomes for patients referred between 2015–2017 (n = 156) to those referred between 2018–2020 (n = 280). Semi-structured phone interviews were conducted with 6 patients per time period and with 6 nephrology providers in the Denver Metro Area. Patients and providers were asked to evaluate communication, transplant education, and overall experience. Results When comparing the two time periods, there was a significant increase in the percentage of patients being referred (79.5% increase, p-0.008) and evaluated for transplant (82.4% increase, p = 0.02) during 2018–2020. While the number of committee reviews and number waitlisted increased during 2018–2020, it did not reach statistical significance (82.9% increase, p = 0.37 and 79.5% increase, p = 0.75, respectively. During patient and provider interviews, we identified 4 themes reflecting participation in the HKTP: improved communication, enhanced patient education, improved experience and areas for advancement. Overall, patients and providers reported a positive experience with the HKTP and noted improved patient understanding of the transplantation process. Conclusions The establishment of the HKTP is associated with a significant increase in Spanish-speaking Hispanic patients being referred and evaluated for kidney transplantation.
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Affiliation(s)
- Madhura Pande
- Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Monica Grafals
- Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.,Colorado Center for Transplant Care, Research and Education (CCTCARE), Aurora, CO, USA
| | - Katherine Rizzolo
- Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Elizabeth Pomfret
- Colorado Center for Transplant Care, Research and Education (CCTCARE), Aurora, CO, USA.,Division of Transplant Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jessica Kendrick
- Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
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Shrestha P, Van Pilsum Rasmussen SE, King EA, Gordon EJ, Faden RR, Segev DL, Humbyrd CJ, McAdams-DeMarco M. Defining the ethical considerations surrounding kidney transplantation for frail and cognitively impaired patients: a Delphi study of geriatric transplant experts. BMC Geriatr 2022; 22:566. [PMID: 35804289 PMCID: PMC9264705 DOI: 10.1186/s12877-022-03209-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 06/06/2022] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Among adult kidney transplant (KT) candidates, 21% are frail and 55% have cognitive impairment, increasing the risk of pre- and post-KT mortality. Centers often assess frailty status and cognitive function during transplant evaluation to help identify appropriate candidate. Yet, there are no ethical guidelines regarding the use of frailty and cognitive function during this evaluation. We seek to develop a clinical consensus on balancing utility and justice in access to KT for frail and cognitively impaired patients. METHODS Twenty-seven experts caring for ESRD patients completed a two-round Delphi panel designed to facilitate consensus (> 80% agreement). RESULTS Experts believed that denying patients transplantation based solely on expected patient survival was inequitable to frail or cognitively impaired candidates; 100% agreed that frailty and cognitive impairment are important factors to consider during KT evaluation. There was consensus that health related quality of life and social support are important to consider before waitlisting frail or cognitively impaired patients. Experts identified important factors to consider before waitlisting frail (likely to benefit from KT, frailty reversibility, age, and medical contraindications) and cognitively impaired (degree of impairment and medication adherence) patients. CONCLUSIONS Clinical experts believed it was ethically unacceptable to allocate organs solely based on patients' expected survival; frailty and cognitive impairment should be measured at evaluation when weighed against other clinical factors. Ethical guidelines regarding the use of frailty and cognitive function during KT evaluation ought to be developed.
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Affiliation(s)
- Prakriti Shrestha
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Elizabeth A King
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elisa J Gordon
- Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ruth R Faden
- Johns Hopkins Berman Institute of Bioethics, Baltimore, MD, USA
- Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Casey Jo Humbyrd
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Mara McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
- Department of Surgery, New York University, New York, USA.
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Tawhari M, Radwi M. A Three-Year Experience With Overseas Kidney Transplantation in a Tertiary Transplant Center in Saudi Arabia. Cureus 2022; 14:e23988. [PMID: 35419250 PMCID: PMC8994614 DOI: 10.7759/cureus.23988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2022] [Indexed: 11/06/2022] Open
Abstract
Background Overseas kidney transplantation is known to be associated with adverse outcomes. In this study, we aim to present a detailed analysis of our three years of experience with overseas kidney transplantation at one of the largest kidney transplant referral sites in the Kingdom of Saudi Arabia. Materials and methods A retrospective cohort study included patients who underwent kidney transplantation overseas and were subsequently followed up at King Abdulaziz Medical City from January 2016 to July 31, 2019. In addition, we compared the outcomes of the patients who underwent kidney transplantation overseas with a cohort of patients who were transplanted locally within the same period. Patients in both cohorts had to have at least one year of follow-up post-transplantation. Results We included a total of 51 patients who underwent kidney transplantation overseas. The mean age of the cohort was 44.7 years, and 69% were male. Almost 60% of the cohort had one or no comorbidity prior to transplant, with hypertension (84%) and diabetes mellitus (37%) being the leading comorbidities. The cause of end-stage kidney disease was unknown in 55% of our patients. In those who had an identifiable cause, lupus nephropathy and diabetes were the most common causes of kidney failure. In comparison with the locally transplanted cohort, no difference was detected between these groups in their baseline characteristics, type or number of comorbidities, medical or surgical complications postoperatively, and one-year mortality. However, we found that the graft rejection rate was significantly higher in patients transplanted overseas (OR=5.4, p<0.001). In addition, the proportion of patients who received anti-thymocyte globulin (ATG) induction was also less in the group with overseas kidney transplantation (58% vs. 22%, p<0.001). Conclusion Overseas transplantation is associated with an increased risk for graft rejection. Our study suggests that overseas kidney transplantation is possibly driven by a lack of donors, especially cadaveric. Counseling patients about risks associated with overseas kidney transplantation and encouraging the public to register for organ donation after death may help curb out this practice.
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Affiliation(s)
- Mohammed Tawhari
- Nephrology, King Abdulaziz Medical City, Riyadh, SAU
- Nephrology, King Abdullah International Medical Research Center, Riyadh, SAU
- Nephrology, King Saud Bin Abdulaziz University for Health Sciences, College of Medicine, Riyadh, SAU
| | - Mansoor Radwi
- Department of Hematology, University of Jeddah, College of Medicine, Jeddah, SAU
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