Referral for Kidney Transplantation in Canadian Provinces

Assessing survival post-kidney transplantation in Australia: A multivariable prediction model

AIM

Kidney transplantation remains the preferred standard of care for patients with kidney failure. Most patients do not access this treatment and wide variations exist in which patients access transplantation. We sought to develop a model to estimate post-kidney transplant survival to inform more accurate comparisons of access to kidney transplantation.

METHODS

Development and validation of prediction models using demographic and clinical data from the Australia and New Zealand Dialysis and Transplant Registry. Adult deceased donor kidney only transplant recipients between 2000 and 2020 were included. Cox proportional hazards regression methods were used with a primary outcome of patient survival. Models were evaluated using Harrell's C-statistic for discrimination, and calibration plots, predicted survival probabilities and Akaike Information Criterion for goodness-of-fit.

RESULTS

The model development and validation cohorts included 11 302 participants. Most participants were male (62.8%) and Caucasian (79.2%). Glomerulonephritis was the most common cause of kidney disease (45.6%). The final model included recipient, donor, and transplant related variables. The model had good discrimination (C-statistic, 0.72; 95% confidence interval (CI) 0.70-0.74 in the development cohort, 0.70; 95% CI 0.67-0.73 in the validation cohort and 0.72; 95% CI 0.69-0.75 in the temporal cohort) and was well calibrated.

CONCLUSION

We developed a statistical model that predicts post-kidney transplant survival in Australian kidney failure patients. This model will aid in assessing the suitability of kidney transplantation for patients with kidney failure. Survival estimates can be used to make more informed comparisons of access to transplantation between units to better measure equity of access to organ transplantation.

Patient and Provider Gender and Kidney Transplant Referral in Canada: A Survey of Canadian Healthcare Providers

BACKGROUND

Referral for kidney transplant (KT) is variable, with women often disadvantaged. This study aimed to better characterize Canadian transplant referral practices and identify potential differences by respondent and/or patient gender using surveys targeted at healthcare practitioners (HCPs) involved in KT.

METHODS

Surveys consisting of 25 complex patient cases representing 7 themes were distributed to KT HCPs across Canada (March 3, 2022-April 27, 2022) using national nephrology/transplant society email registries. Respondents were asked whether they would refer the patient for transplant. Two identical surveys were created, differing only by gender/gender pronouns used in each case. Multivariable logistic regression was used to assess the association of respondent demographics and patient themes (including case gender) with the odds of transplant referral (overall and stratifying by respondent gender).

RESULTS

Overall, the referral rate was 58.0% among 97 survey respondents (46.4% male). Case themes associated with a lower likelihood of referral included adherence concerns (adjusted odds ratio [aOR] 0.65; 95% confidence interval [CI], 0.45-0.94), medical complexity (aOR 0.57; 95% CI, 0.38-0.85), and perceived frailty (aOR 0.63; 95% CI, 0.47-0.84). Respondent gender was not associated with differences in KT referral (aOR 0.91; 95% CI, 0.65-1.26 for male versus female respondents) but modified the association of frailty (less referral for male than female respondents, P  = 0.005) and medical complexity (less referral for female than male respondents, P  = 0.009) with referral. There were no differences in referral rate by case gender ( P  = 0.82).

CONCLUSIONS

KT referral practices vary among Canadian HCPs. In this study, there were no differences in likelihood of transplant referral by candidate gender.

Identifying the barriers to kidney transplantation for patients in rural and remote areas: a scoping review

BACKGROUND

Populations in rural and remote areas have higher rates of chronic kidney disease and kidney failure than those in urban or metropolitan areas, and mortality rates for chronic kidney disease are almost twice as high in remote areas compared to major cities. Despite this, patients residing in regional, rural, or remote areas are less likely to be wait-listed for or receive a kidney transplant. The objective of this scoping review is to identify specific barriers to kidney transplantation for adult patients residing in rural and remote areas from the perspectives of health professionals and patients/carers.

METHODS

Studies were identified through database (MEDLINE, CINAHL, Emcare, Scopus) searches and assessed against inclusion criteria to determine eligibility. A descriptive content analysis was undertaken to identify and describe barriers as key themes.

RESULTS

The 24 selected studies included both quantitative (n = 5) and qualitative (n = 19) methodologies. In studies conducted in health professional populations (n = 10) the most prevalent themes identified were perceived social and cultural issues (80%), burden of travel and distance from treatment (60%), and system-level factors as barriers (60%). In patient/carer populations (n = 14), the most prevalent themes were limited understanding of illness and treatment options (71%), dislocation from family and support network (71%), and physical and psychosocial effects of treatment (71%).

CONCLUSIONS

Patients in regional, rural, and remote areas face many additional barriers to kidney transplantation, which are predominantly associated with the need to travel or relocate to access required medical testing and transplantation facilities.

Access to treatment in chronic kidney disease, dialysis and transplantation. Is there gender equality?

Sex and gender are often used as synonyms. However, while sex describes only a biological state, gender is a dynamic concept that takes into account psychosocial and cultural aspects of human existence that can change according to place and time. Inequality in medicine has been described in several areas. Among them, gender inequality has been disregarded for many years and is now a matter of concern. Chronic kidney disease (CKD) is a growing epidemic worldwide, affecting approximately 10% of the population. Although both men and women are affected, gender equality, especially in access to different treatments, is a matter of concern. We decided to investigate gender equality in patients with CKD. To this end, we conducted a literature narrative review to determine whether gender inequalities were found in CKD patients in general and in access to different treatment modalities in particular. A non-language restricted search was performed until November 30th 2022 in PubMed, SciELO, Trip Database, Google Scholar, MEDES y MEDLINE. We also investigated the situation in this regard in our country. We found that CKD is more prevalent in women than men, nevertheless this prevalence decreases along the CKD stages to the point that more men reach end stage kidney disease (ESKD) and dialysis. Access to transplant (ATT) is higher in men than in women although posttransplant survival shows no gender differences. Finally, most series have shown that women are more frequently Kidney transplantation (KT) living donors than men. Results in our country are similar to the published literature with the exception of a higher proportion of men as KT living donors. As in other areas, gender inequality in Nephrology has been largely overlooked. In this review we have highlighted gender differences in CKD patients. Gender inequality in Nephrology exists and needs to be looked upon in order to reach a personalized clinical approach.

Variation in Kidney Transplant Referral Across Chronic Kidney Disease Programs in Ontario, Canada

Background

Eligible patients with kidney failure should have equal access to kidney transplantation. Transplant referral is the first crucial step toward receiving a kidney transplant; however, studies suggest substantial variation in the rate of kidney transplant referral across regions. The province of Ontario, Canada, has a public, single-payer health care system with 27 regional chronic kidney disease (CKD) programs. The probability of being referred for kidney transplant may not be equal across CKD programs.

Objective

To determine whether there is variability in kidney transplant referral rates across Ontario's CKD programs.

Design

Population-based cohort study using linked administrative health care databases from January 1, 2013, to November 1, 2016.

Setting

Twenty-seven regional CKD programs in the province of Ontario, Canada.

Patients

Patients approaching the need for dialysis (advanced CKD) and patients receiving maintenance dialysis (maximum follow-up: November 1, 2017).

Measurements

Kidney transplant referral.

Methods

We calculated the 1-year unadjusted cumulative probability of kidney transplant referral for Ontario's 27 CKD programs using the complement of Kaplan-Meier estimator. We calculated standardized referral ratios (SRRs) for each CKD program, using expected referrals from a 2-staged Cox proportional hazards model, adjusting for patient characteristics in the first stage. Standardized referral ratios with a value less than 1 were below the provincial average (maximum possible follow-up of 4 years 10 months). In an additional analysis, we grouped CKD programs according to 5 geographic regions.

Results

Among 8641 patients with advanced CKD, the 1-year cumulative probability of kidney transplant referral ranged from 0.9% (95% confidence interval [CI]: 0.2%-3.7%) to 21.0% (95% CI: 17.5%-25.2%) across the 27 CKD programs. The adjusted SRR ranged from 0.2 (95% CI: 0.1-0.4) to 4.2 (95% CI: 2.1-7.5). Among 6852 patients receiving maintenance dialysis, the 1-year cumulative probability of transplant referral ranged from 6.4% (95% CI: 4.0%-10.2%) to 34.5% (95% CI: 29.5%-40.1%) across CKD programs. The adjusted SRR ranged from 0.2 (95% CI: 0.1-0.3) to 1.8 (95% CI: 1.6-2.1). When we grouped CKD programs according to geographic region, we found that patients residing in Northern regions had a substantially lower 1-year cumulative probability of transplant referral.

Limitations

Our cumulative probability estimates only captured referrals within the first year of advanced CKD or maintenance dialysis initiation.

Conclusions

There is marked variability in the probability of kidney transplant referral across CKD programs operating in a publicly funded health care system.

The Feasibility of a Transitional Care Unit for Patients Newly Started on In-Center Hemodialysis: A Research Letter

Background:

Patients with end-stage kidney disease face high mortality and morbidity after dialysis initiation. Transitional care units (TCUs) are typically 4- to 8-week structured multidisciplinary programs targeted toward patients starting hemodialysis during this high-risk time in their care. The goals of such programs are to provide psychosocial support, provide dialysis modality education, and reduce risks of complications. Despite apparent benefits, the TCU model may be challenging to implement, and the effect on patient outcomes is unclear.

Objective:

To assess a newly created multidisciplinary TCUs’ feasibility for patients newly started on hemodialysis.

Design:

Before-and-after study.

Setting:

Kingston Health Sciences Centre hemodialysis unit in Ontario, Canada.

Patients:

We considered all adult patients (age 18+) who initiated in-center maintenance hemodialysis eligible for the TCU program, although patients on infection control precautions and evening shifts were not able to receive TCU care due to staffing limitations.

Measurements:

We defined feasibility as eligible patients completing the TCU program in a timely fashion without additional need for space, no signal of harm, and without explicit concerns from TCU staff or patients at weekly meetings. Key outcomes at 6 months included mortality, proportion hospitalized, dialysis modality, vascular access, initiation of transplant workup, and code status.

Methods:

The TCU care consisted of 1:1 nursing and education until predefined clinical stability and dialysis decisions were satisfied. We compared outcomes among the pre-TCU cohort who initiated hemodialysis between June 2017 and May 2018, and TCU patients who initiated dialysis between June 2018 and March 2019. We summarized outcomes descriptively, along with unadjusted odds ratios (ORs) and 95% confidence intervals (CIs).

Results:

We included 115 pre-TCU patients and 109 post-TCU patients, of whom 49/109 (45%) entered and completed the TCU. The most common reasons for not participating in the TCU included evening hemodialysis shifts (18/60, 30%) or contact precautions (18/60, 30%). The TCU patients completed the program in a median of 35 (25-47) days. We observed no differences in mortality (9% vs 8%; OR = 0.93, 95% CI = 0.28-3.13) or proportion hospitalized (38% vs 39%; OR = 1.02, 95% CI = 0.51-2.03) between the pre-TCU cohort and TCU patients. There was also no difference in use of home dialysis (16% vs 10%; OR = 1.67, 95% CI = 0.64-4.39), non-catheter access (32% vs 25%; OR = 1.44, 95% CI = 0.69-2.98), initiation of transplant workup (14% vs 12%; OR 1.67; 95% CI = 0.64-4.39), and choosing “do not resuscitate” (DNR) orders (22% vs 19%; OR = 1.22, 95% CI = 0.54-2.77). There was no negative patient or staff feedback on the program.

Limitations:

Small sample size and potential for selection bias given inability to provide TCU care for patients on infection control precautions or evening shifts.

Conclusions:

The TCU accommodated a large number of patients, who completed the program in a timely fashion. The TCU model was determined to be feasible at our center. There was no difference in outcomes due to the small sample size. Future work at our center is required to expand the number of TCU dialysis chairs to evening shifts and evaluate the TCU model in prospective, controlled studies.

A Population-Based Analysis of the Impact of the COVID-19 Pandemic on Solid Organ Transplantation in Ontario, Canada: Policy Response and Changes in Volume and 90-Day Outcomes

Objectives

To evaluate the impact of the COVID-19 pandemic on solid organ transplantation.

Background

COVID-19 caused unprecedented disruption to solid organ transplantation (kidney, liver, heart, lung). Concerns about safety and decreases in deceased donors due to pandemic lockdowns have been described as potential causes.

Methods

We report population-based rates of transplantation during the first 3 waves of COVID-19 in Ontario, Canada (March 1, 2020-July 3, 2021) versus a pre-COVID-19 baseline period (January 1, 2017-February 29, 2020). Poisson models were used to predict transplantation rates during COVID-19, based on pre-COVID-19 rates, and generate observed to expected rate ratios (RRs). Ninety-day transplant outcomes (mortality, retransplantation, transplant nephrectomy) were captured.

Results

A 34.4% decrease (RR, 0.656; 95% confidence interval [CI], 0.586-0.734) in transplant rates was observed, coinciding with wave 1 and the deployment of a provincial transplant triaging system. Transplants decreased by 14.6% in wave 2 (RR, 0.854; 95% CI, 0.770-0.947) and 23.1% in wave 3 (RR, 0.769; 95% CI, 0.690-0.857) despite the triaging system not being activated. Overall, there was a 24.3% decrease (RR, 0.757; 95% CI, 0.679-0.844) in transplant rates, equivalent to 409 fewer transplants. No sustained changes were observed in heart or liver but sustained and large decreases were seen for lung (RR, 0.664; 95% CI, 0.482-0.915) and kidney (RR, 0.721; 95% CI, 0.602-0.863) transplantation. A low prevalence (1.7%) of COVID-19 infection within 90 days of transplantation was seen. No differences were observed in other 90-day outcomes.

Conclusions

Early safety concerns limited transplantation to immediate life-saving procedures; however, the reductions in kidney and lung transplants continued for the rest of the pandemic, where no restrictions were in place.

Transplantation of Patients With Long Dialysis Vintage in the Current Deceased Donor Kidney Allocation System (KAS)

RATIONALE & OBJECTIVE

In 2014 the wait-time calculation for deceased donor kidney transplantation in the United States was changed from the date of first waitlisting to the date of first maintenance dialysis treatment with the aim of minimizing disparities in access to transplantation. This study examined the impact of this policy on access to transplantation, patient survival, and transplant outcomes among patients treated with maintenance dialysis for a prolonged duration before waitlisting.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

Patients identified in the US Renal Data System between 2008 and 2018 aged 18-70 years and in the 95th percentile of dialysis treatment duration (≥6.5 years) before waitlisting.

EXPOSURE

Waitlisting for transplantation before versus after implementation of the policy.

OUTCOME

Time from date of waitlisting to deceased donor transplantation and death, and from date of transplantation to all cause graft loss.

ANALYTICAL APPROACH

Univariate and multivariable time to event analyses.

RESULTS

Patients waitlisted after the policy change had a higher likelihood of deceased donor transplantation (HR, 3.12 [95% CI, 2.90-3.37]) and lower risk of death (HR, 0.74 [95% CI, 0.63-0.87]). The risk of graft loss was lower in the post-kidney allocation system (KAS) cohort (HR, 0.66 [95% CI, 0.55-0.80]). The proportion of adult patients treated with dialysis ≥6.5 years who were never waitlisted for transplantation remained high (73%) and did not decrease after the policy implementation.

LIMITATIONS

Cannot determine causality in this observational study.

CONCLUSIONS

The policy change was associated with an increase in deceased donor transplantation and marked improvement in patient survival for patients waitlisted after long periods of dialysis treatment without decreasing the utility of available deceased donor kidney supply. The policy was not associated with increased waitlisting of this disadvantaged population.

Using Administrative Health Care Databases to Identify Patients With End-Stage Kidney Disease With No Recorded Contraindication to Receiving a Kidney Transplant

Background

Administrative health care databases can be efficiently analyzed to describe the degree to which patients with end-stage kidney disease (ESKD) have access to kidney transplantation. Measures of access to transplantation are better represented when restricting to only those patients eligible to receive a kidney transplant. The way administrative data can be used to assess kidney transplant eligibility in the absence of clinical data has not been well described.

Objective

To demonstrate a method that uses administrative health care databases to identify patients with ESKD who have no recorded contraindication to receiving a kidney transplant.

Design and setting

Population-based cohort study using linked administrative health care databases in Ontario, Canada.

Patients

Adult patients with ESKD approaching the need for dialysis (predialysis) or receiving maintenance dialysis between January 1, 2013 and March 31, 2015 in Ontario, Canada.

Measurements

Recipient of a kidney-only or kidney-pancreas transplant.

Methods

We assessed more than 80 baseline characteristics, including demographic information, comorbidities, kidney-specific characteristics, and referral and listing criteria for kidney transplantation. We compared these characteristics between patients who did and did not receive a kidney transplant.

Results

We included 23 642 patients with ESKD (11 195 who were predialysis and 12 447 receiving maintenance dialysis). Over a median follow-up of 3.2 years (25th, 75th percentile: 1.3, 5.6), 3215 (13.6%) received a kidney-only or kidney-pancreas transplant. Of the studied characteristics available in administrative databases, >97% of patients with one or more of these characteristics did not receive a kidney transplant during follow-up: ESKD-modified Charlson Comorbidity Index score ≥7 (a higher score represents greater comorbidity), home oxygen use, age above 75 years, dementia, living in a long-term care facility, receiving at least one physician house call in the past year, and a combination of select malignancies (ie, lung, lymphoma, cervical, colorectal, liver, active multiple myeloma, and bladder cancer). Using these combined criteria reduced the total number of patients from 23 642 to 12 539 with no recorded contraindications to transplant (a 47% reduction), while the proportion who received a kidney transplant changed from 13.6% (denominator of 23 642) to 24.9% (denominator of 12 539).

Limitations

Administrative databases are unable to capture all the complexities of determining transplant eligibility.

Conclusion

We identified several criteria available within administrative health care databases that can be used to identify patients with ESKD who have no recorded contraindications to kidney transplant. These criteria could be applied when reporting measures of access to kidney transplantation that require knowledge of transplant eligibility.

Patient Experience in Pancreas-Kidney Transplantation-A Methodological Approach Towards Innovation in an Established Program

Simultaneous pancreas-kidney transplantation (SPKT) leads to increased survival and quality of life, and is an alternative treatment for insulin-dependent diabetes mellitus and end-stage kidney disease. Due to the particularities of this population (often with multiple comorbidities) and of the surgery (only performed in a few centers), a comprehensive analysis of patients' experience along the SPKT process is crucial to improve patient care and add value to this procedure. Therefore, we applied a systematic and iterative methodology with the participation of both patients and professional teams working together to explore and identify unmet needs and value-adding steps along the transplant patient journey at an established pancreas transplant program. Four main steps (to comprehend, to explore, to experiment and to assess) led to several interventions around three major areas: Administration and logistics, information and communication, and perceived quality of assistance. As a result, both displacements to the hospital for diagnostic purposes and the time delay involved in joining the patient waiting list for transplantation were reduced in parallel to the administrative procedures. In conclusion, the methodological implementation of key organizational changes has great impact on overall patient experience. Further quantitative analysis from the patient's perspective will consolidate our program and may add new prototype service design components.

Gender Disparities in Kidney Transplantation Referral Vary by Age and Race – A Multi-Regional Cohort Study in the Southeast US

Introduction

Methods

Results

Conclusion

Immunosuppressant Medication Use in Patients with Kidney Allograft Failure: A Prospective Multi-Center Canadian Cohort Study

Background: Patients with kidney transplant failure have a high risk of hospitalization and death due to infection. The optimal use of immunosuppressants after transplant failure remains uncertain and clinical practice varies widely. Methods: This prospective cohort study enrolled patients within 21 days of starting dialysis after transplant failure in 16 Canadian centers. Immunosuppressant medication use, death, hospitalized infection, rejection of the failed allograft, and panel reactive anti-HLA antibodies (PRA) were determined at 1, 3, 6 , and 12 months and bi-annually until death, repeat transplantation, or loss to follow-up. Results: The 269 study patients were followed for a median of 558 days. There were 33 deaths, 143 patients hospitalized for infection, and 21 rejections. Most patients (65%) continued immunosuppressants, 20% continued prednisone only, while 15% discontinued all immunosuppressants. In multivariable models, patients who continued immunosuppressants had a lower risk of death (HR =0.40, 95% CI, 0.17-0.93) and were not at increased risk of hospitalized infection (HR 1.81; 95% CI 0.82 to 4.0) compared to patients who discontinued all immunosuppressants or continued prednisone only. The mean class I and class II PRA increased from 11% to 27% and 25% to 47%, respectively, but did not differ by immunosuppressant use. Continuation of immunosuppressants was not protective of rejection of the failed allograft (HR 0.81, 95% CI, 0.22-2.94). Conclusions: Prolonged use of immunosuppressants greater than one year after transplant failure was not associated with a higher risk of death or hospitalized infection but was insufficient to prevent higher anti-HLA antibodies or rejection of the failed allograft.

An Environmental Scan and Evaluation of Quality Indicators Across Canadian Kidney Transplant Centers

Background:

Kidney transplantation is the optimal treatment for an individual requiring kidney replacement therapy, resulting in improved survival and quality of life while costing the health care system less than maintenance dialysis. Achieving and maintaining a kidney transplant requires extensive coordination of several different health care services. To improve the quality of kidney transplant care, quality metrics or indicators that encompass all aspects of the individual’s journey to transplant should be measured in a standardized fashion.

Objective:

To identify, categorize, and evaluate strengths and weaknesses of kidney transplant quality indicators currently being used across Canada.

Design:

An environmental scan of quality indicators being used by kidney organizations and programs.

Setting:

A 16-member volunteer pan-Canadian panel with expertise in nephrology, transplant, and quality improvement.

Sample:

Transplant programs, as well as provincial transplant and kidney agencies across Canada.

Methods:

Indicators were first categorized based on the period of transplant care and then using the Institute of Medicine and Donabedian frameworks. A 4-member subcommittee rated each indicator using a modified version of the Delphi consensus technique based on the American College of Physician/Agency for Healthcare Research and Quality criteria. Consensus ratings were subsequently shared with the entire 16-member panel for additional comments.

Results:

We identified 46 measures related to transplant care across 7 Canadian provinces (9 referral and evaluation, 9 waitlist activity and outcomes, 6 hospitalization for transplant surgery, 12 posttransplant care, 6 organ utilization, 4 living donor). We rated 24 indicators (52%) as necessary to distinguish high-quality from low-quality care, most of which measured effective (n = 10) or efficient (n = 6) care. Only 7 (15%) of 46 indicators evaluated person-centered or equitable care. Fourteen common indicators were measured by 5 of 7 provinces, 10 of which were deemed “necessary,” measuring safe (n = 2), effective (n = 5), efficient (n = 2), and equitable (n = 1) care.

Limitations:

The panel lacked patient and allied health representation.

Conclusions:

There are a large number of kidney transplant quality indicators currently being used in Canada, some of which are common across provinces and focus primarily on measuring effective care. Person-centered and equitable care indicators were lacking, and only half of these indicators were deemed “necessary” for quality improvement. Our results should complement ongoing work to achieve national consensus on the standardization of quality indicators in kidney transplantation.

International Society of Nephrology Global Kidney Health Atlas: structures, organization, and services for the management of kidney failure in North America and the Caribbean

The International Society of Nephrology established the Global Kidney Health Atlas project to define the global capacity for kidney replacement therapy and conservative kidney care, and this second iteration was to describe the availability, accessibility, quality, and affordability of kidney failure (KF) care worldwide. This report presents results for the International Society of Nephrology North America and the Caribbean region. Relative to other regions, the North America and Caribbean region had better infrastructure and funding for health care and more health care workers relative to the population. Various essential medicines were also more available and accessible. There was substantial variation in the prevalence of treated KF in the region, ranging from 137.4 per million population (pmp) in Jamaica to 2196 pmp in the United States. A mix of public and private funding systems cover costs for nondialysis chronic kidney disease care in 60% of countries and for dialysis in 70% of countries. Although the median number of nephrologists is 18.1 (interquartile range, 15.3-29.5) pmp, which is approximately twice the global median of 9.9 (interquartile range, 1.2-22.7) pmp, some countries reported shortages of other health care workers. Dialysis was available in all countries, but peritoneal dialysis was underutilized and unavailable in Barbados, Cayman Islands, and Turks and Caicos. Kidney transplantation was primarily available in Canada and the United States. Economic factors were the major barriers to optimal KF care in the Caribbean countries, and few countries in the region have chronic kidney disease-specific national health care policies. To address regional gaps in KF care delivery, efforts should be directed toward augmenting the workforce, improving the monitoring and reporting of kidney replacement therapy indicators, and implementing noncommunicable disease and chronic kidney disease-specific policies in all countries.

Barriers to Accessing Kidney Transplantation Among Populations Marginalized by Race and Ethnicity in Canada: A Scoping Review Part 2-East Asian, South Asian, and African, Caribbean, and Black Canadians

BACKGROUND

Kidney transplantation (KT), a treatment option for end-stage kidney disease (ESKD), is associated with longer survival and improved quality of life compared with dialysis. Inequities in access to KT, and specifically, living donor kidney transplantation (LDKT), have been documented in Canada, along various demographic dimensions. In this article, we review existing evidence about inequitable access to KT and LDKT for patients from communities marginalized by race and ethnicity in Canada.

OBJECTIVE

To characterize the currently published data on rates of KT and LDKT among East Asian, South Asian, and African, Caribbean, and Black (ACB) Canadian communities and to answer the research question, "what factors may influence inequitable access to KT among East Asian, South Asian, and ACB Canadian communities?."

ELIGIBILITY CRITERIA

Databases and gray literature were searched in June and November 2020 for full-text original research articles or gray literature resources addressing KT access or barriers in East Asian, South Asian, and ACB Canadian communities. A total of 25 articles were analyzed thematically.

SOURCES OF EVIDENCE

Gray literature and CINAHL, OVID Medline, OVID Embase, and Cochrane databases.

CHARTING METHODS

Literature characteristics were recorded and findings which described rates of and factors that influence access to KT were summarized in a narrative account. Key themes were subsequently identified and synthesized thematically in the review.

RESULTS

East Asian, South Asian, and ACB communities in Canada face barriers in accessing culturally appropriate medical knowledge and care and experience inequitable access to KT. Potential barriers include gaps in knowledge about ESKD and KT, religious and spiritual concerns, stigma of ESKD and KT, health beliefs, social determinants of health, and experiences of systemic racism in health care.

LIMITATIONS

This review included literature that used various methodologies and did not assess study quality. Data on ethnicity and race were not reported or defined in a standardized manner. The communities examined in this review are not homogeneous and views on organ donation and KT vary by individual.

CONCLUSIONS

Our review has identified potential barriers for communities marginalized by race and ethnicity in accessing KT and LDKT. Further research is urgently needed to better understand the barriers and support needs of these communities, and to develop strategies to improve equitable access to LDKT for the growingly diverse population in Canada.

Thematic Analysis of the Health Records of a National Sample of US Veterans With Advanced Kidney Disease Evaluated for Transplant

IMPORTANCE

To be considered for a kidney transplant, patients with advanced kidney disease must participate in a formal evaluation and selection process. Little is known about how this process proceeds in real-world clinical settings.

OBJECTIVE

To characterize the transplant evaluation process among a representative national sample of US veterans with advanced kidney disease who were referred to a kidney transplant center.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study was a thematic analysis of clinician notes in the electronic health records of US veterans referred for kidney transplant evaluation. In a random sample of 4000 patients with advanced kidney disease between January 1, 2004, and December 31, 2014, cared for in the US Department of Veterans Affairs (VA) health care system, there were 211 patients who were referred to a transplant center during the follow-up period. This group was included in the qualitative analysis and was followed up until their date of death or the end of the follow-up period on October 8, 2019.

MAIN OUTCOMES AND MEASURES

Dominant themes pertaining to the kidney transplant evaluation and selection process identified through thematic analysis.

RESULTS

Among 211 study patients, the mean (SD) age was 57.9 (9.5) years, and 202 patients (95.7%) were male. The following 4 dominant themes regarding the transplant evaluation process emerged: (1) far-reaching and inflexible medical evaluation, in which patients were expected to complete an extensive evaluation that could have substantial physical and emotional consequences, made little accommodation for their personal values and needs, and impacted other aspects of their care; (2) psychosocial valuation, in which the psychosocial component of the transplant assessment could be subjective and intrusive and could place substantial demands on patients' family members; (3) surveillance over compliance, in which the patients' ability and willingness to follow medical recommendations was an important criterion for transplant candidacy and their adherence to a wide range of recommendations and treatments was closely monitored; and (4) disempowerment and lack of transparency, in which patients and their local clinicians were often unsure about what to expect during the evaluation process or about the rationale for selection decisions. For the evaluation process to proceed, local clinicians had to follow transplant center requirements even when they believed the requirements did not align with best practices or the patients' needs.

CONCLUSIONS AND RELEVANCE

In this qualitative study of US veterans with advanced kidney disease evaluated for transplant, clinician documentation in the medical record indicated that, to be considered for a kidney transplant, patients were required to participate in a rigid, demanding, and opaque evaluation and selection process over which they and their local clinicians had little control. These findings highlight the need for a more evidence-based, individualized, and collaborative approach to kidney transplant evaluation.

Dialysis facility referral and start of evaluation for kidney transplantation among patients treated with dialysis in the Southeastern United States

Variability in transplant access exists, but barriers to referral and evaluation are underexplored due to lack of national surveillance data. We examined referral for kidney transplantation evaluation and start of the evaluation among 34 857 incident, adult (18-79 years) end-stage kidney disease patients from 690 dialysis facilities in the United States Renal Data System from January 1, 2012 through August 31, 2016, followed through February 2018 and linked data to referral and evaluation data from nine transplant centers in Georgia, North Carolina, and South Carolina. Multivariable-adjusted competing risk analysis examined each outcome. The median within-facility cumulative percentage of patients referred for kidney transplantation within 1 year of dialysis at the 690 dialysis facilities in Network 6 was 33.7% (interquartile range [IQR]: 25.3%-43.1%). Only 48.3% of referred patients started the transplant evaluation within 6 months of referral. In multivariable analyses, factors associated with referral vs evaluation start among those referred at any time differed. For example, black, non-Hispanic patients had a higher rate of referral (hazard ratio [HR]: 1.22; 95% confidence interval [CI]: 1.18-1.27), but lower evaluation start among those referred (HR: 0.93; 95% CI: 0.88-0.98), vs white non-Hispanic patients. Barriers to transplant varied by step, and national surveillance data should be collected on early transplant steps to improve transplant access.

An opt-out model for kidney transplant referral: The time has come

Disparities that affect equity in access to kidney transplantation for patients with kidney failure have been well described. Many robust clinical trials have tested the effectiveness of interventions to reduce disparities and equilibrate access to kidney transplantation. Moreover, policy changes have been enacted to achieve the same aims. Despite these efforts, rates of kidney transplant waitlisting within the first year of end-stage kidney disease have remained unchanged over the past 2 decades, while incident rates of end-stage kidney disease have climbed. Because prior interventions have not durably increased transplant access, disruptive change is clearly needed. The Advancing American Kidney Health Executive Order sets bold goals to transform kidney care for patients and caregivers. In this spirit, we discuss an Opt-Out for Transplant Referral Model as a compelling solution to improve equity in access to kidney transplantation.

Can financial rewards complement altruism to raise deceased organ donation rates?

BACKGROUND

Organ supply-demand in developing countries worldwide has continued to widen. Hence, using a large survey (n ¼ 10,412), this study seeks to investigate whether human psychology could be used to inculcate philanthropy to raise deceased organ donation rates.

METHODS

Three models were constructed to examine multidimensional relationships among the variables. Structural equation modeling was applied to estimate the direct and indirect influence of altruism, financial incentives, donation perception, and socioeconomic status simultaneously on willingness to donate deceased organs.

ETHICAL CONSIDERATIONS

The study was approved by the University of Malaya ethics committee.

RESULTS

The results show that altruism amplifies the impact of socioeconomic status and donation perception on willingness to donate. Also, the results show that financial incentives cannot complement altruism to raise organ donation rates. Hence, investing in education and public awareness enhances altruism in people, which then increases the propensity to donate.

CONCLUSION

Evidence suggests that governments should allocate resources to increase public awareness about organ donation. Awareness programs about the importance of philanthropic donations and the participation of medical consultants at hospitals in the processes form the foundation of such a presumptive approach.

Peptidomic Analysis of Urine from Youths with Early Type 1 Diabetes Reveals Novel Bioactivity of Uromodulin Peptides In Vitro

Chronic hyperglycemia is known to disrupt the proteolytic milieu, initiating compensatory and maladaptive pathways in the diabetic kidney. Such changes in intrarenal proteolysis are captured by the urinary peptidome. To elucidate the early kidney response to chronic hyperglycemia, we conducted a peptidomic investigation into urines from otherwise healthy youths with type 1 diabetes and their non-diabetic peers using unbiased and targeted mass spectrometry-based techniques. This cross-sectional study included two separate cohorts for the discovery (n = 30) and internal validation (n = 30) of differential peptide excretion. Peptide bioactivity was predicted using PeptideRanker and subsequently verified in vitro Proteasix and the Nephroseq database were used to identify putative proteases responsible for peptide generation and examine their expression in diabetic nephropathy. A total of 6550 urinary peptides were identified in the discovery analysis. We further examined the subset of 162 peptides, which were quantified across all thirty samples. Of the 15 differentially excreted peptides (p < 0.05), seven derived from a C-terminal region (589SGSVIDQSRVLNLGPITRK607) of uromodulin, a kidney-specific protein. Increased excretion of five uromodulin peptides was replicated in the validation cohort using parallel reaction monitoring (p < 0.05). One of the validated peptides (SGSVIDQSRVLNLGPI) activated NFκB and AP-1 signaling, stimulated cytokine release, and enhanced neutrophil migration in vitro. In silico analyses highlighted several potential proteases such as hepsin, meprin A, and cathepsin B to be responsible for generating these peptides. In summary, we identified a urinary signature of uromodulin peptides associated with early type 1 diabetes before clinical manifestations of kidney disease and discovered novel bioactivity of uromodulin peptides in vitro Our present findings lay the groundwork for future studies to validate peptide excretion in larger and broader populations, to investigate the role of bioactive uromodulin peptides in high glucose conditions, and to examine proteases that cleave uromodulin.

Policies to promote timely referral for kidney transplantation

There are numerous patient, provider, and health system barriers to accessing kidney transplantation. Patient barriers such as sociocultural and clinical characteristics and provider factors such as provider knowledge and awareness of transplantation play important roles in facilitating transplant. Health system factors like misaligned incentives and quality metrics for dialysis facilities and transplant centers also influence transplant access. While numerous studies have documented the impact of these barriers on wait-listing and transplant, few studies have examined referral from a dialysis facility to a transplant center and start of the transplant evaluation process. While the Centers for Medicare and Medicaid Services (CMS) require that dialysis facilities educate patients about transplant, there are no guidelines for the content and objectives for this education. In addition, policies to require timely referral for transplantation have been considered by CMS but are difficult to implement without national data on referral. Federal policies should be amended to mandate transplant center submission of referral data-while decreasing the unfunded mandate to collect other unusable data currently collected as part of regulatory monitoring of transplant centers-to promote timely access to transplant, increased transplant rates, and to better understand the multilevel barriers and facilitators to transplant referral.