Pre-emptive live donor kidney transplantation-moving barriers to opportunities: An ethical, legal and psychological aspects of organ transplantation view

What are the benefits of preemptive versus non-preemptive kidney transplantation? A systematic review and meta-analysis

Opting for a preemptive kidney transplant (PKT) can help avoid costs and morbidity associated with dialysis. However, while multiple studies have shown clinical benefits of PKT, other studies have not demonstrated this, leading to controversy in the literature regarding the exact benefits of PKT. Therefore, this study aimed to determine the clinical outcomes of PKT versus non-preemptive kidney transplantation (nPKT) in adult patients. Multiple databases were searched up to May 4, 2022. Independent reviewers selected studies for inclusion and extracted relevant data. Risk of bias was assessed using the Downs and Black checklist. Eighty-seven studies including 859,715 adult kidney transplant patients were included the review. The risk of patient death (relative risk [95% confidence interval] 0.74 [0.60-0.91]) was significantly lower in PKT versus nPKT patients for living donor (LD) transplants, whereas the risk of overall graft loss was significantly lower in PKT compared to nPKT patients for both LD (0.72 [0.62-0.83]) as well as deceased donor (DD) transplants (0.80 [0.69-0.92]). The evidence suggests that LD PKT patients have a lower risk of patient death and graft loss compared to nPKT patients, and DD PKT patients have a lower risk of graft loss than nPKT patients.

Barriers and facilitators to the transplant process among patients living with polycystic kidney disease: a qualitative Approach

BACKGROUND

Kidney transplant is the gold standard for renal replacement therapy in patients with autosomal dominant polycystic kidney disease (ADPKD), which is the fourth leading cause of kidney failure. Despite the medical and economic benefits of preemptive kidney transplant over dialysis before transplant, only 9-21% of qualifying patients receive preemptive transplants. Given the low rates of preemptive transplant, the aim of this study was to determine perceived facilitators and barriers to preemptive transplant among ADPKD patients using a qualitative approach.

METHODS

Data were collected between July 2021 and January 2022 from virtual individual semi-structured interviews of 16 adult participants with ADPKD. Qualitative analysis of the recorded interviews was conducted to generate themes.

RESULTS

Our findings revealed two themes specific for facilitators to preemptive transplant (social support and patient agency) and three themes specific to barriers for preemptive transplant (inadequate social support, gaps in knowledge, and institutional and systemic policies). The results also include various subthemes and the application of these themes to the social ecological model.

CONCLUSIONS

These findings suggest that increasing social support and patient agency, such as through patient navigator programs and encouraging effective communication between health care providers and patients, can facilitate the transplant process. Increasing dissemination of transplant knowledge from institutions and systems to patients through paired kidney exchange education and live donor outreach can also increase timely access to preemptive kidney transplants for patients with ADPKD. Our findings are limited by our single site study in the US, which may not apply to individuals experiencing different social, cultural, and health access conditions.

Process control: simply a matter of efficiency or of survival and costs? A single-centre quality improvement project in living donor renal transplant

BACKGROUND

Rising incidence and prevalence of end-stage renal disease is a worldwide concern for sustainability of healthcare systems and societies. Living donor renal transplant [LDRT] provides highest health achievements and cost containment than any alternative form of renal replacement therapy. Nonetheless, about 25% of potential LDRTs are missed for causes directly related with inadequate timing in donor assessment. Our quality improvement (QI) project implement process control tools and strategy aiming at reducing total evaluation time for donor candidates and minimizing dialysis exposure for intended recipients, which are the two main determinants of clinical outcomes and costs.

METHODS

The study includes patients who underwent donor nephrectomy between January 1, 2017 and December 31, 2021. Six Sigma DMAIC approach was adopted to assess Base Case performance (Jan2017-Jun2019) and to design and implement our QI project. Study of current state analysis focused on distribution of time intervals within the assessment process, analysis of roles and impacts of involved healthcare providers and identification of targets of improvement. Improved Scenario (Jul2019-Dec2021) was assessed in terms of total lead time reduction, total pre-transplantation dialysis exposure and costs reduction, and increase in pre-emptive transplantations. The study was reported following SQUIRE 2.0 Guidelines for QI projects.

RESULTS

Study population includes 63 patients, 37 in Base Case and 26 in Improved Scenario. Total lead time reduced from a median of 293 to 166 days and this in turn reduced pre-transplantation dialysis exposure and costs by 45%. Rate of potential pre-emptive donors' loss changes from 44% to 27%.

CONCLUSIONS

Lean methodology is an effective tool to improve quality and efficiency of healthcare processes, in the interest of patients, healthcare professionals and payers.

The impact of COVID-19 on kidney transplant care

The SARS-CoV-2 virus precipitated the coronavirus 2019 (COVID-19) pandemic, which placed considerable strain on healthcare systems and necessitated immediate and rapid alterations in the delivery of healthcare. In the transplant population, COVID-19 directly impacts an inherently vulnerable population in the setting of immunosuppression and co-morbidities, but also further complicates the clinical evaluation and management of kidney transplant candidates and recipients in a strained healthcare environment being challenged by the pandemic. Many transplant centers around the world saw mortality rate spikes in organ recipients related to COVID-19, and changes in care delivery abound. This review evaluates the care of the kidney transplant patient through all phases of the process including pre-operative evaluations, perioperative care, post-transplantation considerations, and how the global pandemic has changed the way we care for our patients.

Living Donor Kidney Transplantation in Older Individuals: An Ethical Legal and Psychological Aspects of Transplantation (ELPAT) View

Living donor transplantation is the optimal treatment for suitable patients with end-stage kidney disease. There are particular advantages for older individuals in terms of elective surgery, timely transplantation, and early graft function. Yet, despite the superiority of living donor transplantation especially for this cohort, older patients are significantly less likely to access this treatment modality than younger age groups. However, given the changing population demographic in recent decades, there are increasing numbers of older but otherwise healthy individuals with kidney disease who could benefit from living donor transplantation. The complex reasons for this inequity of access are explored, including conscious and unconscious age-related bias by healthcare professionals, concerns relating to older living donors, ethical anxieties related to younger adults donating to aging patients, unwillingness of potential older recipients to consider living donation, and the relevant legislation. There is a legal and moral duty to consider the inequity of access to living donor transplantation, recognising both the potential disparity between chronological and physiological age in older patients, and benefits of this treatment for individuals as well as society.

Pancreas Transplantation in Black, Asian and Minority Ethnic Patients-Single Centre Experience in the UK

Ethnic disparities in the outcomes after simultaneous pancreas kidney (SPK) transplantation still exist. The influence of ethnicity on the outcomes of pancreas transplantation in the UK has not been reported and hence we aimed to investigate our cohort. A retrospective analysis of all pancreas transplant recipients (n = 171; Caucasians = 118/Black Asian Ethnic Minorities, BAME = 53) from 2006 to 2020 was done. The median follow-up was 80 months. Patient & pancreas graft survival, rejection rate, steroid free maintenance rate, HbA1c, weight gain, and the incidence of secondary diabetic complications post-transplant were compared between the groups. p < 0.003 was considered significant (corrected for multiple hypothesis testing). Immunosuppression consisted of alemtuzumab induction and steroid free maintenance with tacrolimus and mycophenolate mofetil. Pancreas graft & patient survival were equivalent in both the groups. BAME recipients had a higher prevalence of type-2 diabetes mellitus pre-transplant (BAME = 30.19% vs. Caucasians = 0.85%, p < 0.0001), and waited for a similar time to transplantation once waitlisted, although pre-emptive SPK transplantation rate was higher for Caucasian recipients (Caucasians = 78.5% vs. BAME = 0.85%, p < 0.0001). Despite equivalent rejections & steroid usage, BAME recipients gained more weight (BAME = 7.7% vs. Caucasians = 1.8%, p = 0.001), but had similar HbA1c (functioning grafts) at 3-,12-, 36-, and 60-months post-transplant.

[Long-term physical and psychological consequences of chronic kidney disease]

Aufgrund der verbesserten Behandlungsoptionen können Patient:innen mit chronischen Nierenerkrankungen heute deutlich länger überleben als noch vor 10 Jahren. Das Überleben ist für die Betroffenen jedoch immer mit einem Verlust an Lebensqualität verbunden. In diesem Beitrag wird eine kurze Übersicht über die körperlichen und psychischen Erkrankungsfolgen, Begleiterkrankungen und Therapienebenwirkungen bei chronischen Nierenerkrankungen gegeben. Auf bisher bekannte Auswirkungen der COVID-19-Pandemie wird hingewiesen. Abschließend wird aufgezeigt, wie die Langzeitbehandlung weiterentwickelt werden sollte, um die Lebensqualität der Patient:innen zu erhöhen.

Funktionseinschränkungen der Niere haben aufgrund der Kontamination des Blutes mit harnpflichtigen Substanzen (Urämie) schwere Auswirkungen auf den Gesamtorganismus. Zusätzlich sind die Patient:innen von Nebenwirkungen betroffen, die im Zusammenhang mit der medikamentösen Therapie, Dialyse oder Nierentransplantation auftreten können. Patient:innen und Angehörige sind einer großen psychischen Belastung ausgesetzt. Infektionen mit SARS-CoV‑2 können die Nierenfunktion beeinträchtigen und auch die Prognose einer bereits bestehenden Erkrankung verschlechtern.

Die ganzheitliche Versorgung der Patient:innen mit chronischen Nierenerkrankungen muss neben der medizinischen Versorgung auch die psychologischen und psychosozialen Aspekte berücksichtigen. Nephrologie und Psychonephrologie müssen Hand in Hand weiterentwickelt werden, um die medizinische Versorgung und Lebensqualität der betroffenen Patient:innen zu verbessern.

The Impact of Cold Ischaemia Time on Outcomes of Living Donor Kidney Transplantation: A Systematic Review and Meta-Analysis

Studies have been carried out to investigate the effect of a prolonged cold ischaemia time (CIT) on the outcomes of living donor kidney transplantation (LDKT). There is no clear consensus in the literature about the effects of CIT on LDKT outcomes, and therefore, we performed a systematic review and meta-analysis to provide evidence on this subject. Searches were performed in five databases up to 12 July 2021. Articles comparing different CIT in LDKT describing delayed graft function (DGF), graft and patient survival, and acute rejection were considered for inclusion. This study is registered with PROSPERO, CRD42019131438. In total, 1452 articles were found, of which eight were finally eligible, including a total of 164,179 patients. Meta-analyses showed significantly lower incidence of DGF (odds ratio (OR) = 0.61, p < 0.01), and significantly higher 1-year graft survival (OR = 0.72, p < 0.001) and 5-year graft survival (OR = 0.88, p = 0.04), for CIT of less than 4 h. Our results underline the need to keep CIT as short as possible in LDKT (ideally < 4 h), as a shorter CIT in LDKT is associated with a statistically significant lower incidence of DGF and higher graft survival compared to a prolonged CIT. However, clinical impact seems limited, and therefore, in LDKT programmes in which the CIT might be prolonged, such as kidney exchange programmes, the benefits outweigh the risks. To minimize these risks, it is worth considering including CIT in kidney allocation algorithms and in general take precautions to protect high risk donor/recipient combinations.