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Josephson MA, Becker Y, Budde K, Kasiske BL, Kiberd BA, Loupy A, Małyszko J, Mannon RB, Tönshoff B, Cheung M, Jadoul M, Winkelmayer WC, Zeier M. Challenges in the management of the kidney allograft: from decline to failure: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2023; 104:1076-1091. [PMID: 37236423 DOI: 10.1016/j.kint.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 05/11/2023] [Accepted: 05/12/2023] [Indexed: 05/28/2023]
Abstract
In March 2022, Kidney Disease: Improving Global Outcomes (KDIGO) held a virtual Controversies Conference to address the important but rarely examined phase during which the kidney transplant is failing or has failed. In addition to discussing the definition of a failing allograft, 4 broad areas were considered in the context of a declining functioning graft: prognosis and kidney failure trajectory; immunosuppression strategies; management of medical and psychological complications, and patient factors; and choice of kidney replacement therapy or supportive care following graft loss. Identifying and paying special attention to individuals with failing allografts was felt to be important in order to prepare patients psychologically, manage immunosuppression, address complications, prepare for dialysis and/or retransplantation, and transition to supportive care. Accurate prognostication tools, although not yet widely available, were embraced as necessary to define allograft survival trajectories and the likelihood of allograft failure. The decision of whether to withdraw or continue immunosuppression after allograft failure was deemed to be based most appropriately on risk-benefit analysis and likelihood of retransplantation within a few months. Psychological preparation and support was identified as a critical factor in patient adjustment to graft failure, as was early communication. Several models of care were noted that enabled a medically supportive transition back to dialysis or retransplantation. Emphasis was placed on the importance of dialysis-access readiness before initiation of dialysis, in order to avoid use of central venous catheters. The centrality of the patient to all management decisions and discussions was deemed to be paramount. Patient "activation," which can be defined as engaged agency, was seen as the most effective way to achieve success. Unresolved controversies, gaps in knowledge, and areas for research were also stressed in the conference deliberations.
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Affiliation(s)
- Michelle A Josephson
- Section of Nephrology, Department of Medicine, and Transplant Institute, University of Chicago, Chicago, Illinois, USA.
| | - Yolanda Becker
- Transplantation Institute, Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Bertram L Kasiske
- Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota, USA
| | - Bryce A Kiberd
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Alexandre Loupy
- Université Paris Cité, INSERM U970, Paris Institute for Transplantation and Organ Regeneration, F-75015 Paris, France; Department of Kidney Transplantation, Necker Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Jolanta Małyszko
- Department of Nephrology, Dialysis and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Roslyn B Mannon
- Division of Nephrology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Burkhard Tönshoff
- Department of Pediatrics I, University Children's Hospital Heidelberg, Heidelberg, Germany
| | - Michael Cheung
- Kidney Disease: Improving Global Outcomes (KDIGO), Brussels, Belgium
| | - Michel Jadoul
- Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Martin Zeier
- Division of Nephrology, University of Heidelberg, Heidelberg, Germany.
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Foley ME, Vinson AJ, Skinner TAA, Kiberd BA, Tennankore KK. The Impact of Combined Warm and Cold Ischemia Time on Post-transplant Outcomes. Can J Kidney Health Dis 2023; 10:20543581231178960. [PMID: 37333478 PMCID: PMC10272701 DOI: 10.1177/20543581231178960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 04/05/2023] [Indexed: 06/20/2023] Open
Abstract
Background Prolonged warm ischemia time (WIT) and cold ischemia time (CIT) are independently associated with post-transplant graft failure; their combined impact has not been previously studied. We explored the effect of combined WIT/CIT on all-cause graft failure following kidney transplantation. Methods The Scientific Registry of Transplant Recipients was used to identify kidney transplant recipients from January 2000 to March 2015 (after which WIT was no longer separately reported), and patients were followed until September 2017. A combined WIT/CIT variable (excluding extreme values) was separately derived for live and deceased donor recipients using cubic splines; for live donor recipients, the reference group was WIT 10 to <23 minutes and CIT >0 to <0.42 hours, and for deceased donor recipients the WIT was 10 to <25 minutes and CIT 1 to <7.75 hours. The adjusted association between combined WIT/CIT and all-cause graft failure (including death) was analyzed using Cox regression. Secondary outcomes included delayed graft function (DGF). Results A total of 137 125 recipients were included. For live donor recipients, patients with prolonged WIT/CIT (60 to ≤120 minutes/3.04 to ≤24 hours) had the highest adjusted hazard ratio (HR) for graft failure (HR = 1.61, 95% confidence interval [CI] = 1.14-2.29 relative to the reference group). For deceased donor recipients, a WIT/CIT of 63 to ≤120 minutes/28 to ≤48 hours was associated with an adjusted HR of 1.35 (95% CI = 1.16-1.58). Prolonged WIT/CIT was also associated with DGF for both groups although the impact was more driven by CIT. Conclusions Combined WIT/CIT is associated with graft loss following transplantation. Acknowledging that these are separate variables with different determinants, we emphasize the importance of capturing WIT and CIT independently. Furthermore, efforts to reduce WIT and CIT should be prioritized.
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Affiliation(s)
- Martha E. Foley
- Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Amanda J. Vinson
- Nova Scotia Health, Halifax, Canada
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, Canada
| | - Thomas A. A. Skinner
- Nova Scotia Health, Halifax, Canada
- Department of Urology, Dalhousie University, Halifax, NS, Canada
| | - Bryce A. Kiberd
- Nova Scotia Health, Halifax, Canada
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, Canada
| | - Karthik K. Tennankore
- Nova Scotia Health, Halifax, Canada
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, Canada
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Kiberd BA, Tennankore KK, Vinson AJ. Comparing the Net Benefits of Adult Deceased Donor Kidney Transplantation for a Patient on the Preemptive Waiting List vs a Patient Receiving Dialysis. JAMA Netw Open 2022; 5:e2223325. [PMID: 35867058 PMCID: PMC9308061 DOI: 10.1001/jamanetworkopen.2022.23325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
IMPORTANCE Preemptive kidney transplantation is the preferred treatment for end-stage kidney disease. However, deceased donor (DD) kidneys are limited, and the net benefit of allocating kidneys to a preemptively waitlisted patient rather than to a patient receiving dialysis is unclear. OBJECTIVE To estimate the net benefit and costs of allocating kidneys to preemptively waitlisted patients vs those receiving dialysis. DESIGN, SETTING, AND PARTICIPANTS This medical decision analytical model used data from the 2020 US Renal Data System to calculate patient survival among waitlisted patients who received a DD kidney transplant. Four patients were simulated, with similar characteristics: (1) a patient on the preemptive waiting list receiving a DD transplant, (2) a patient on the preemptive waiting list never receiving a transplant, (3) a waitlisted patient already receiving dialysis (dialysis vintage <1 year) receiving a transplant, and (4) a waitlisted patient already receiving dialysis (dialysis vintage <1 year) never receiving a transplant. Annual probability of initiating dialysis (for patients 1 and 2) and duration of dialysis (for patients 3 and 4) were varied in sensitivity analyses. EXPOSURES Allocating a DD kidney to a patient on the preemptive waiting list vs the same kidney to a patient receiving dialysis for less than 1 year, with similar recipient characteristics. MAIN OUTCOMES AND MEASURES Differences in projected quality-adjusted life-years (QALYs) and total costs. RESULTS In a simulated patient with a mean start age of 50 years (range, 30-64 years), the patient receiving a preemptive DD transplantation experienced 10.58 (95% CI, 10.36-10.80) QALYs, and the patient on the preemptive waiting list never transplanted experienced 6.83 (95% CI, 6.67-6.99) QALYs. The patient receiving DD transplantation after less than 1 year of dialysis experienced 10.33 (95% CI, 10.21-10.55) QALYs, and the patient receiving dialysis who remained on the waiting list experienced 6.20 (95% CI, 6.04-6.36) QALYs; allocating a DD kidney to the preemptive patient added 3.75 (95% CI, 3.57-3.93) QALYs, whereas allocating the kidney to the patient already receiving dialysis added 4.13 (95% CI, 3.92-4.31) QALYs. While the estimated posttransplant survival was longest for the preemptive transplant recipient, preferentially allocating the kidney to the preemptive patient results in 0.39 (95% CI, 0.49-0.29) fewer QALYs. The net cost of preemptive transplantation was $54 100 (95% CI, $44 100-$64 100) more than transplantation to a waitlisted patient. If the rate of transitioning to dialysis was 20 (rather than 33) events per 100 patient waiting list-years, the net QALYs were -0.67 (95% CI, -0.78 to -0.56). If the patient was receiving dialysis for 3 to 4 years (vs <1 year) the net benefit was not significantly different; however, net costs were considerably higher for the preemptive option. CONCLUSIONS AND RELEVANCE In this decision analytic model study, although allocating DD kidneys to patients preemptively was the best option from a patient perspective, allocating DD kidneys to patients receiving dialysis was a better use of a scare resource from a societal perspective.
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Affiliation(s)
- Bryce A. Kiberd
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Karthik K. Tennankore
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Amanda J. Vinson
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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Vinson AJ, Thanamayooran A, Kiberd BA, West K, Siddiqi FS, Gunaratnam L, Tennankore KK. The Association of Pre-Transplant C-Peptide Level with the Development of Post-Transplant Diabetes: A Cohort Study. Kidney360 2022; 3:1738-1745. [PMID: 36514718 PMCID: PMC9717663 DOI: 10.34067/kid.0003742022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 06/28/2022] [Indexed: 01/12/2023]
Abstract
Background Post-transplant diabetes mellitus (PTDM) is an important complication after kidney transplantation that results in reduced patient and allograft survival. Although there are established risk factors for PTDM, whether pretransplant C-peptide levels associate with PTDM is unknown. Therefore, in this study, we aimed to examine the association of pretransplant C-peptide levels with PTDM. Methods This was a cohort study of nondiabetic adult patients who underwent kidney transplant in Nova Scotia, Canada, between January 1, 2016, and March 31, 2021, with fasting C-peptide levels measured before transplant. Multivariable logistic regression was used to determine the association of pretransplant C-peptide (dichotomized around the median) with PTDM at 1 year post transplant. Given the known association between pretransplant obesity and PTDM, we repeated our primary analysis in a cohort restricted to a BMI of 20-35 kg/m2. Results The median C-peptide value was 3251 (Q1 2480, Q3 4724); pretransplant C-peptide level was dichotomized at 3000 pmol/L. PTDM occurred in 25 (19%) individuals. Thirty percent of patients in the high and only 2% of patients in the low C-peptide groups developed PTDM (P<0.001). A C-peptide level ≥3000 pmol/L was strongly associated with PTDM in multivariable analysis (OR=18.9, 95% CI, 2.06 to 174.2). In a restricted cohort with a BMI of 20-35 kg/m2, an elevated pretransplant C-peptide remained independently associated with the risk of PTDM (OR=15.7, 95% CI, 1.64 to 150.3). C-peptide was the only factor independently associated with PTDM in this restricted BMI cohort. Conclusions A pretransplant C-peptide level ≥3000 pmol/L was associated with a nearly 20-fold increased odds of PTDM at 1 year post kidney transplantation. Identifying patients with high pretransplant C-peptide levels may therefore help identify those at risk for PTDM who may benefit from focused preventative and therapeutic interventions and support.
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Affiliation(s)
- Amanda J. Vinson
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, Canada
| | - Aran Thanamayooran
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, Canada
| | - Bryce A. Kiberd
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, Canada
| | - Kenneth West
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, Canada
| | - Ferhan S. Siddiqi
- Division of Endocrinology and Metabolism, Department of Medicine, Dalhousie University, Halifax, Canada
| | - Lakshman Gunaratnam
- Multiorgan Transplant Program, London Health Sciences Centre, London, Canada,Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Karthik K. Tennankore
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, Canada
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Abstract
IMPORTANCE In the US, live donor (LD) kidney transplant rates have decreased in pediatric recipients. Pediatric patients with kidney failure will likely need more than 1 kidney transplant during their lifetime, but the optimal sequence of transplant (ie, deceased donor [DD] followed by LD or vice versa) is not known. OBJECTIVE To determine whether pediatric recipients should first receive a DD allograft followed by an LD allograft (DD-LD sequence) or an LD allograft followed by a DD allograft (LD-DD sequence). DESIGN, SETTING, AND PARTICIPANTS This decision analytical model examined US pediatric patients with kidney failure included in the US Renal Data System 2019 Report who were waiting for a kidney transplant, received a transplant, or experienced graft failure. INTERVENTIONS Kidney transplant sequences of LD-DD vs DD-LD. MAIN OUTCOMES AND MEASURES Difference in projected life-years between the 2 sequence options. RESULTS Among patients included in the analysis, the LD-DD sequence provided more net life-years in those 5 years of age (1.82 [95% CI, 0.87-2.77]) and 20 years of age (2.23 [95% CI, 1.31-3.15]) compared with the DD-LD sequence. The net outcomes in patients 10 years of age (0.36 [95% CI, -0.51 to 1.23] additional life-years) and 15 years of age (0.64 [95% CI, -0.15 to 1.39] additional life-years) were not significantly different. However, for those aged 10 years, an LD-DD sequence was favored if eligibility for a second transplant was low (2.09 [95% CI, 1.20-2.98] additional life-years) or if the LD was no longer available (2.32 [95% CI, 1.52-3.12] additional life-years). For those aged 15 years, the LD-DD sequence was favored if the eligibility for a second transplant was low (1.84 [95% CI, 0.96-2.72] additional life-years) or if the LD was no longer available (2.49 [95% CI, 1.77-3.27] additional life-years). Access to multiple DD transplants did not compensate for missing the LD opportunity. CONCLUSIONS AND RELEVANCE These findings suggest that the decreased use of LD kidney transplants in pediatric recipients during the past 2 decades should be scrutinized. Given the uncertainty of future recipient eligibility for retransplant and future availability of an LD transplant, the LD-DD sequence is likely the better option. This strategy of an LD transplant first would not only benefit pediatric recipients but allow DD kidneys to be used by others who do not have an LD option.
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Affiliation(s)
- Bryce A. Kiberd
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Amanda Vinson
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Philip D. Acott
- Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
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Vinson AJ, Kiberd BA, West K, Mannon RB, Foster BJ, Tennankore KK. Disparities in Access to Preemptive Repeat Kidney Transplant: Still Missing the Mark? Kidney360 2021; 3:144-152. [PMID: 35368561 PMCID: PMC8967618 DOI: 10.34067/kid.0003162021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 10/18/2021] [Indexed: 01/10/2023]
Abstract
Background The need for repeat transplant due to failing kidney allografts is increasing over time. The benefit of preemptive kidney retransplant (PKre-T) is controversial. Marginalized populations are less likely to undergo their first transplant preemptively; however, whether inequities exist for those undergoing PKre-T is unknown. Methods We performed a cohort study of adult patients undergoing live and deceased kidney transplant in the United States from 2000 to 2018 identified using the Scientific Registry of Transplant Recipients, and we identified patients with first preemptive kidney transplant (PKT) and PKre-T. In the primary analysis, a multivariable logistic regression was used to identify independent predictors of PKre-T. In secondary analyses, multivariable Cox models were used to determine the association of PKre-T with death-censored and all-cause graft loss. Results In total, 4910 (15.5%) patients underwent PKre-T, and 43,293 (19.1%) underwent first PKT. Inequities in access to PKre-T persisted (OR, 0.49; 95% CI, 0.44 to 0.55 for unemployed versus full time; OR, 1.61; 95% CI, 1.14 to 2.25 for graduate school versus not completing high school; OR, 0.61; 95% CI, 0.52 to 0.70 for Black versus White race); 7.1% of all transplanted Black patients received PKre-T versus 17.4% of White patients. Women were more likely to undergo PKre-T than men (OR, 1.42; 95% CI, 1.29 to 1.57). PKre-T was associated with superior graft survival relative to retransplant after a period of dialysis (HR, 0.73; 95% CI, 0.67 to 0.80 for all-cause graft failure; HR, 0.72; 95% CI, 0.65 to 0.81 for death-censored graft loss). Conclusions Despite improved patient and graft survival, inequities in access to PKre-T persist. Patients with lower education, patients with reduced employment status, patients of Black race, and men are less likely to receive PKre-T.
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Affiliation(s)
- Amanda J. Vinson
- Division of Nephrology, Department of Medicine, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada,Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Bryce A. Kiberd
- Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Kenneth West
- Division of Nephrology, Department of Medicine, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada,Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Roslyn B. Mannon
- Division of Nephrology, Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Bethany J. Foster
- Division of Nephrology, Montreal Children’s Hospital of the McGill University Health Centre, Montreal, Quebec, Canada,Department of Pediatrics, McGill University, Montreal, Quebec, Canada,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Karthik K. Tennankore
- Division of Nephrology, Department of Medicine, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada,Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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Vinson AJ, Tennankore KK, Kiberd BA. Donor-Recipient Matching in Kidney Transplant: We're Not There Yet. Transplant Proc 2021; 53:1909-1914. [PMID: 34272053 DOI: 10.1016/j.transproceed.2021.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 04/20/2021] [Accepted: 05/04/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Strategic organ allocation is expected to prolong patient and graft survival after transplant. This study explored differences in graft survival when kidneys are allocated based on strategic donor-recipient (D-R) pairing vs with the existing Kidney Allocation System (KAS). METHODS Using the Scientific Registry of Transplant Recipients from 2000 to 2014, we used a multivariable Cox model to assess the hazard ratios (HRs) for death or graft failure among 3 hypothetical donor kidneys transplanted into 3 hypothetical recipients, relative to an ideally matched D-R pair. Median predicted survival for each of the 9 possible D-R pairing combinations was determined, and outcomes for strategic D-R pairing were compared with those obtained using the KAS for allocation. RESULTS A total of 31,607 patients (29.7%) died or developed graft loss over the study period. Strategic allocation of kidneys resulted in HRs for graft loss of 1.74 (95% confidence interval [CI], 1.41-2.14), 1.82 (95% CI, 1.46-2.26), and 1.74 (95% CI 1.38-2.19) for recipients 1, 2 and 3 respectively, whereas by following the KAS, HRs were 1.93 (95%, CI 1.63-2.28), 2.06 (95% CI, 1.74-2.44), and 1.93 (95% CI, 1.58-2.37); corresponding to 3.84, 11.39, and 7.40 months longer predicted patient or graft survival for recipients 1, 2 and 3 with strategic D-R pairing compared with the KAS. CONCLUSIONS Allocation of kidneys by strategic D-R pairing may improve graft survival relative to allocation using the KAS.
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Affiliation(s)
- A J Vinson
- (a)Division of Nephrology, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada; Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.
| | - K K Tennankore
- (a)Division of Nephrology, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada; Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - B A Kiberd
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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Worthen G, Vinson A, Cardinal H, Doucette S, Gogan N, Gunaratnam L, Keough-Ryan T, Kiberd BA, Prasad B, Rockwood K, Sills L, Suri RS, Tangri N, Walsh M, West K, Yohanna S, Tennankore K. Prevalence of Frailty in Patients Referred to the Kidney Transplant Waitlist. Kidney360 2021; 2:1287-1295. [PMID: 35369656 PMCID: PMC8676383 DOI: 10.34067/kid.0001892021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 05/13/2021] [Indexed: 02/07/2023]
Abstract
Background Comparisons between frailty assessment tools for waitlist candidates are a recognized priority area for kidney transplantation. We compared the prevalence of frailty using three established tools in a cohort of waitlist candidates. Methods Waitlist candidates were prospectively enrolled from 2016 to 2020 across five centers. Frailty was measured using the Frailty Phenotype (FP), a 37-variable frailty index (FI), and the Clinical Frailty Scale (CFS). The FI and CFS were dichotomized using established cutoffs. Agreement was compared using κ coefficients. Area under the receiver operating characteristic (ROC) curves were generated to compare the FI and CFS (treated as continuous measures) with the FP. Unadjusted associations between each frailty measure and time to death or waitlist withdrawal were determined using an unadjusted Cox proportional hazards model. Results Of 542 enrolled patients, 64% were male, 80% were White, and the mean age was 54±14 years. The prevalence of frailty by the FP was 16%. The mean FI score was 0.23±0.14, and the prevalence of frailty was 38% (score of ≥0.25). The median CFS score was three (IQR, 2-3), and the prevalence was 15% (score of ≥4). The κ values comparing the FP with the FI (0.44) and CFS (0.27) showed fair to moderate agreement. The area under the ROC curves for the FP and FI/CFS were 0.86 (good) and 0.69 (poor), respectively. Frailty by the CFS (HR, 2.10; 95% CI, 1.04 to 4.24) and FI (HR, 1.79; 95% CI, 1.00 to 3.21) was associated with death or permanent withdrawal. The association between frailty by the FP and death/withdrawal was not statistically significant (HR, 1.78; 95% CI, 0.79 to 3.71). Conclusion Frailty prevalence varies by the measurement tool used, and agreement between these measurements is fair to moderate. This has implications for determining the optimal frailty screening tool for use in those being evaluated for kidney transplant.
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Affiliation(s)
- George Worthen
- Division of Nephrology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Amanda Vinson
- Division of Nephrology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Héloise Cardinal
- Division of Nephrology, Centre de Recherche du CHUM, Montreal, Quebec, Canada
| | | | - Nessa Gogan
- Division of Nephrology, Horizon Health Network, Saint John, New Brunswick, Canada
| | - Lakshman Gunaratnam
- Division of Nephrology, London Health Sciences Center, London, Ontario, Canada
| | - Tammy Keough-Ryan
- Division of Nephrology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Bryce A. Kiberd
- Division of Nephrology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Bhanu Prasad
- Division of Nephrology, Regina General Hospital, Regina, Saskatchewan, Canada
| | - Kenneth Rockwood
- Division of Geriatric Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Laura Sills
- Nova Scotia Health Authority, Halifax, Canada
| | - Rita S. Suri
- Research Institute of the McGill University Health Center and Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Navdeep Tangri
- Chronic Disease Innovation Center, Winnipeg, Manitoba, Canada
| | - Michael Walsh
- Division of Nephrology, McMaster University, Hamilton, Ontario, Canada
| | - Kenneth West
- Division of Nephrology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Seychelle Yohanna
- Division of Nephrology, McMaster University, Hamilton, Ontario, Canada
| | - Karthik Tennankore
- Division of Nephrology, Dalhousie University, Halifax, Nova Scotia, Canada
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Vinson AJ, Kiberd BA, Tennankore KK. In Search of a Better Outcome: Opting Into the Live Donor Paired Kidney Exchange Program. Can J Kidney Health Dis 2021; 8:20543581211017412. [PMID: 34104454 PMCID: PMC8161848 DOI: 10.1177/20543581211017412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 04/02/2021] [Indexed: 11/16/2022] Open
Abstract
Background Live donor (LD) kidney transplantation is the best option for patients with end-stage kidney disease (ESKD). However, this may not be the best option if a patient's donor is older and considerably smaller in weight. Patient (A) with a less than ideal donor (Donor A) might enter into a live donor paired exchange (LDPE) program with the hopes of swapping for a better-quality organ. A second patient (B) who is in the LDPE may or may not benefit from this exchange with Donor A. Methods This medical decision analysis examines the conditions that favor Patient A entering into the LDPE compared to directly accepting a kidney from their intended donor, as well as the circumstances where Patient B also benefits by accepting a lower-quality organ. Results Under select circumstances, a paired exchange could benefit both Patients A and B. For example, a 30-year-old Patient A with a lower-quality donor might gain 1.201.521.84 quality adjusted life years (QALYs) by entering into a LDPE for a better-quality kidney, whereas a 60-year-old Patient B might gain 0.931.031.13 QALYs by accepting Donor A's kidney rather than waiting longer in the LDPE. The net benefit (or loss) of entering the LDPE differs by recipient age, donor organ quality, likelihood of Patient B being transplanted in LDPE, and likelihood of Patient A finding an ideal donor in the LDPE. Conclusion This study shows there are ways to increase live donor utilization and effectiveness that require further research and potentially changes to the LDPE process.
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Affiliation(s)
- Amanda J Vinson
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Bryce A Kiberd
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
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10
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Vinson AJ, Kiberd BA, Tennankore KK. Panic in the Pandemic: When Should Kidney Transplant Programs Close? Kidney Int Rep 2021; 6:1232-1241. [PMID: 34013101 PMCID: PMC8116904 DOI: 10.1016/j.ekir.2021.02.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 02/03/2021] [Accepted: 02/08/2021] [Indexed: 12/24/2022] Open
Abstract
Background Pandemics greatly interfere with overall health care delivery as resources are diverted to combat the crisis. Kidney transplantation programs were closed temporarily during the COVID-19 pandemic. Given the critical shortage of organs, their short shelf life, and their overall importance to improving length and quality of life for those with kidney disease, this analysis examines the impact of discarding deceased donor organs. Methods The net benefit (or harm) of discarding deceased donor organs was measured in projected life years from a societal and individual perspective using a Markov model. A wide range of infection rates, pandemic durations, and case fatality rates associated with infection in wait listed and transplant recipients were examined. Results Overall, patient life expectancy fell for both wait listed and transplant recipients as the pandemic conditions became more unfavorable. However, the overall net benefit of a transplant during the pandemic was preserved. For example, prior to the pandemic, the net benefit of a kidney transplant over dialysis was calculated to be 6.25 life years (LYs) or 8.24 quality-adjusted life years (QALYs) in a 40-year old recipient. This fell to 5.86 LYs (7.78 QALYs) during the pandemic. Even assuming plausible but higher relative case fatality rates and risks of nosocomial and donor transmission in transplant recipients compared to wait listed patients, the net benefit remained >4 years for most deceased donor organs. Conclusion As long as hospitals have adequate resources to deal with the pandemic and can limit nosocomial infection, kidney transplantation should not be curtailed.
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Affiliation(s)
- Amanda J. Vinson
- Department of Medicine, Division of Nephrology, Nova Scotia Health, Halifax, Nova Scotia, Canada
- Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- Correspondence: Amanda J. Vinson, Room 5081, 5 Floor Dickson Building, Victoria General Hospital, 5820 University Avenue, Halifax, Nova Scotia, Canada B3H 1V8.
| | - Bryce A. Kiberd
- Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Karthik K. Tennankore
- Department of Medicine, Division of Nephrology, Nova Scotia Health, Halifax, Nova Scotia, Canada
- Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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11
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Holden RM, Mustafa RA, Alexander RT, Battistella M, Bevilacqua MU, Knoll G, Mac-Way F, Reslerova M, Wald R, Acott PD, Feltmate P, Grill A, Jindal KK, Karsanji M, Kiberd BA, Mahdavi S, McCarron K, Molnar AO, Pinsk M, Rodd C, Soroka SD, Vinson AJ, Zimmerman D, Clase CM. Canadian Society of Nephrology Commentary on the Kidney Disease Improving Global Outcomes 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder. Can J Kidney Health Dis 2020; 7:2054358120944271. [PMID: 32821415 PMCID: PMC7412914 DOI: 10.1177/2054358120944271] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 06/06/2020] [Indexed: 12/23/2022] Open
Abstract
Purpose of review: (1) To provide commentary on the 2017 update to the Kidney Disease Improving Global Outcomes (KDIGO) 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD); (2) to apply the evidence-based guideline update for implementation within the Canadian health care system; (3) to provide comment on the care of children with chronic kidney disease (CKD); and (4) to identify research priorities for Canadian patients. Sources of information: The KDIGO 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of CKD-MBD. Methods: The commentary committee co-chairs selected potential members based on their knowledge of the Canadian kidney community, aiming for wide representation from relevant disciplines, academic and community centers, and different geographical regions. Key findings: We agreed with many of the recommendations in the clinical practice guideline on the diagnosis, evaluation, prevention, and treatment of CKD-MBD. However, based on the uncommon occurrence of abnormalities in calcium and phosphate and the low likelihood of severe abnormalities in parathyroid hormone (PTH), we recommend against screening and monitoring levels of calcium, phosphate, PTH, and alkaline phosphatase in adults with CKD G3. We suggest and recommend monitoring these parameters in adults with CKD G4 and G5, respectively. In children, we agree that monitoring for CKD-MBD should begin in CKD G2, but we suggest measuring ionized calcium, rather than total calcium or calcium adjusted for albumin. With regard to vitamin D, we suggest against routine screening for vitamin D deficiency in adults with CKD G3-G5 and G1T-G5T and suggest following population health recommendations for adequate vitamin D intake. We recommend that the measurement and management of bone mineral density (BMD) be according to general population guidelines in CKD G3 and G3T, but we suggest against routine BMD testing in CKD G4-G5, CKD G4T-5T, and in children with CKD. Based on insufficient data, we also recommend against routine bone biopsy in clinical practice for adults with CKD or CKD-T, or in children with CKD, although we consider it an important research tool. Limitations: The committee relied on the evidence summaries produced by KDIGO. The CSN committee did not replicate or update the systematic reviews.
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Affiliation(s)
- Rachel M Holden
- Division of Nephrology, Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Reem A Mustafa
- Division of Nephrology and Hypertension, Department of Internal Medicine, The University of Kansas Medical Center, Kansas City, USA.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - R Todd Alexander
- Department of Pediatrics and Physiology, University of Alberta, Edmonton, Canada
| | - Marisa Battistella
- University Health Network, Leslie Dan Faculty of Pharmacy, University of Toronto, ON, Canada
| | - Micheli U Bevilacqua
- Division of Nephrology, Department of Medicine, The University of British Columbia, Vancouver, Canada
| | - Greg Knoll
- Division of Nephrology, The Ottawa Hospital, ON, Canada
| | - Fabrice Mac-Way
- Division of Nephrology, CHU de Québec, Hôtel-Dieu de Québec Hospital, Université Laval, Québec City, QC, Canada
| | - Martina Reslerova
- Nephrology Section, St. Boniface General Hospital, University of Manitoba, Winnipeg, Canada
| | - Ron Wald
- Division of Nephrology, St. Michael's Hospital, University of Toronto, ON, Canada
| | - Philip D Acott
- Division of Nephrology, Department of Pediatrics, Dalhousie University, Halifax, NS, Canada
| | - Patrick Feltmate
- Department of Geriatric Medicine, Dalhousie University, Halifax, NS, Canada
| | - Allan Grill
- Department of Family & Community Medicine, University of Toronto, ON, Canada
| | - Kailash K Jindal
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Meena Karsanji
- Professional Practice, Vancouver Coastal Health, Richmond, BC, Canada
| | - Bryce A Kiberd
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Sara Mahdavi
- Department of Nutritional Sciences, University of Toronto, ON, Canada.,Department of Nephrology, Scarborough Health Network, ON, Canada
| | - Kailee McCarron
- Nova Scotia Renal Program, Nova Scotia Health Authority, Halifax, Canada
| | - Amber O Molnar
- Division of Nephrology, McMaster University, Hamilton, ON, Canada
| | - Maury Pinsk
- Division of Nephrology, Department of Pediatrics & Child Health, University of Manitoba, Winnipeg, Canada
| | - Celia Rodd
- Division of Diabetes & Endocrinology, Department of Pediatrics & Child Health, University of Manitoba, Winnipeg, Canada
| | - Steven D Soroka
- Division of Nephrology, Department of Medicine, Dalhousie University, NSHA Renal Program and Pharmacy Services, Halifax, NS, Canada
| | - Amanda J Vinson
- Division of Nephrology, Dalhousie University, Halifax, NS, Canada
| | - Deborah Zimmerman
- Division of Nephrology, Department of Medicine, University of Ottawa, ON, Canada
| | - Catherine M Clase
- Division of Nephrology, Department of Medicine, Department of Health Research, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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12
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Quinn JG, Levy AR, Cheng CK, Doucette S, Theriault C, Doiron D, Kiberd BA, Tennankore KK. A contemporary description of patients' estimated blood losses from diagnostic phlebotomy in a census of hospital episodes from a Canadian tertiary care center. Transfusion 2019; 59:2849-2856. [PMID: 31283032 DOI: 10.1111/trf.15434] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 05/13/2019] [Accepted: 06/08/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Phlebotomy for diagnostic testing is among the commonest hospital procedures, but hospital-wide surveys of all inpatients characterizing blood draw volumes have not been published. The objectives were to characterize the daily blood volumes drawn for diagnostic testing from patients discharged from a Canadian tertiary care center, describe the daily distributions of phlebotomy volumes across service locations, and describe changes in hemoglobin (Hb) and transfusion across service locations. STUDY DESIGN AND METHODS Data were obtained on all patients discharged between 2012 and 2014 using linked discharge abstract and laboratory data. Cumulative daily blood volume and draw frequency were reported by service and days since admission. Changes in Hb and red blood cell (RBC) transfusion rates were reported for nontransfused and transfused patients. RESULTS Data were included on 59,715 subjects. Mean daily estimated blood loss varied from 8.5 ± 6.5 mL/day onward to 27.2 ± 20.0 mL/day in the intensive care unit (ICU; p < 0.001). Phlebotomy volumes were highest on the first day of admission and declined thereafter (p < 0.001). For nontransfused individuals in the first week of admission, Hb levels decreased by the highest percentage in the ICU. The rate of RBC unit transfusion was highest in the ICU (232.4 units/1000 patient-days; 95% confidence interval, 225.8-239.2; p < 0.0001 compared with all other locations). CONCLUSION Considerable variation was observed in estimated blood loss due to diagnostic phlebotomy across different services within one teaching hospital. Thi information is foundational for planning interventions to minimize estimated blood loss from phlebotomy.
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Affiliation(s)
- Jason G Quinn
- Department of Pathology and Laboratory Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.,Department of Pathology and Laboratory Medicine, Nova Scotia Healthy Authority, Halifax, Nova Scotia, Canada
| | - Adrian R Levy
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Calvino K Cheng
- Department of Pathology and Laboratory Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.,Department of Pathology and Laboratory Medicine, Nova Scotia Healthy Authority, Halifax, Nova Scotia, Canada
| | - Steve Doucette
- Research Methods Unit, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Chris Theriault
- Research Methods Unit, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Don Doiron
- Department of Pathology and Laboratory Medicine, Nova Scotia Healthy Authority, Halifax, Nova Scotia, Canada
| | - Bryce A Kiberd
- Department of Pathology and Laboratory Medicine, Nova Scotia Healthy Authority, Halifax, Nova Scotia, Canada.,Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Karthik K Tennankore
- Department of Pathology and Laboratory Medicine, Nova Scotia Healthy Authority, Halifax, Nova Scotia, Canada.,Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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13
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Kiberd BA, Doucette K, Vinson AJ, Tennankore KK. Hepatitis C virus-infected kidney waitlist patients: Treat now or treat later? Am J Transplant 2018; 18:2443-2450. [PMID: 29687948 DOI: 10.1111/ajt.14891] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 03/23/2018] [Accepted: 04/15/2018] [Indexed: 01/25/2023]
Abstract
Currently many but not all centers transplant hepatitis C virus (HCV) viremic positive (+) donor kidneys into HCV+ recipients. Directed donation of HCV+ organs reduces the wait time to transplantation for HCV+ patients. Direct-acting antiviral (DAA) therapy can cure HCV in virtually all who are infected. Some have suggested that treatment of HCV+ waitlisted patients be deferred with the hope that earlier transplantation will provide better outcomes than early DAA therapy. However, there are not enough organs to guarantee prompt transplantation for the current waitlist of infected candidates. A Markov medical decision analysis model was created to compare the overall outcomes of delayed DAA therapy (Option 1) to immediate DAA therapy (Option 2) in waitlisted HCV+ patients. Option 1 patients were modeled to be transplanted 1 year earlier, with a higher cumulative transplant incidence (54% at 5 years post-listing vs 45% for Option 2). Despite this, Option 2 provided 0.43 (95% confidence interval [CI] 0.38-0.49) more life years than Option 1. However, Option 1 was preferred for regions with much greater access to HCV+ organs or in patients with very low HCV+-associated mortality. The best option from an individual patient's perspective will differ by region and candidate.
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Affiliation(s)
- B A Kiberd
- Departments of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - K Doucette
- University of Alberta, Edmonton, Alberta, Canada
| | - A J Vinson
- Departments of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - K K Tennankore
- Departments of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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14
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Kiberd J, Khan U, Stockman C, Radhakrishnan A, Phillips M, Kiberd BA, West KA, Soroka S, Chan C, Tennankore KK. Effectiveness of a Web-Based eHealth Portal for Delivery of Care to Home Dialysis Patients: A Single-Arm Pilot Study. Can J Kidney Health Dis 2018; 5:2054358118794415. [PMID: 30210802 PMCID: PMC6130084 DOI: 10.1177/2054358118794415] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 07/09/2018] [Indexed: 11/16/2022] Open
Abstract
Background Improving a patient's experience with their care through an online interface for communication (an eHealth patient portal) has been shown to be beneficial in some studies of chronic disease populations. However, little is known about the effectiveness of an eHealth portal for delivery of care to home dialysis patients. Objectives Primary: To determine whether an eHealth portal is effective at improving a patient's experience with their home dialysis care. Secondary: (1) To determine whether an eHealth portal improves health-related quality of life for home dialysis patients, (2) to assess patient satisfaction with an eHealth portal and perceived impact on aspects of their home dialysis therapy and health, (3) to determine the acceptability of the eHealth portal software, and (4) to determine the change in telephone usage for communication after patient adoption of an eHealth portal. Design Single-arm pilot trial with recruitment over a 4-month period. Setting The multidisciplinary home dialysis clinic in Halifax Nova Scotia Canada. Patients Adults (>18 years) receiving either home hemodialysis or peritoneal dialysis. Measurements Consumer quality index (CQI), health-related quality of life using the EuroQol Five Dimensions Questionnaire (EQ-5D), acceptability of the eHealth portal software (using the Acceptability E-scale), and satisfaction/perceived impact (using a modified questionnaire). Methods A web-based application (McKesson, Canada, RelayHealth®) allowed patients and health care workers to communicate through a secure, password-protected online portal that permitted visualization of the messaging history by patient and provider. Patients and the home dialysis health care team had the ability to send messages related to patient care at any time including proposed changes to medication, instructions after a clinic visit, times of new appointments, upcoming investigations, or questions about care. Patient experience with home dialysis care using the CQI, health-related quality of life using the EQ-5D, acceptability of the eHealth portal software, and satisfaction/perceived impact were assessed at baseline, 6, and 12 months of follow-up (where applicable). Total minutes of telephone communication was assessed prior to and after adoption of the portal. Results Of the 41 patients who consented to join the portal, 27 (66%) created an online account. At baseline, patients had a positive experience for the care and communication provided by their nephrologist (CQI: 3.63, 95% confidence interval [CI]: 3.50-3.76) and this did not change significantly over the study period. Similar results were observed for the care provided by other nephrology health care team members. Health-related quality of life using the EQ-5D score was 0.80 (interquartile range [IQR]: 0.71-0.83) at baseline and this also did not significantly change over the study period. Patients were satisfied with the eHealth portal (mean Likert scale score of 6.5 ± 0.6 in overall satisfaction, scale ranging from 1 completely dissatisfied to 10 completely satisfied), but only a minority (N = 12) completed a satisfaction questionnaire. Median monthly phone usage decreased from 12.5 to 10 minutes (P = .02) after adoption of the portal. Limitations The study is limited by the small sample size, high rate of patient dropout, and limited response rate. Conclusions In this study of home dialysis patients, we identified that an eHealth communication did not lead to significant improvements in patient experience with home dialysis care. Trial Registration ClinicalTrials.gov number NCT02128347.
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Affiliation(s)
| | - Usman Khan
- Nova Scotia Health Authority, Halifax, Canada
| | | | | | | | - Bryce A Kiberd
- Dalhousie University, Halifax, NS, Canada.,Nova Scotia Health Authority, Halifax, Canada
| | - Kenneth A West
- Dalhousie University, Halifax, NS, Canada.,Nova Scotia Health Authority, Halifax, Canada
| | - Steven Soroka
- Dalhousie University, Halifax, NS, Canada.,Nova Scotia Health Authority, Halifax, Canada
| | | | - Karthik K Tennankore
- Dalhousie University, Halifax, NS, Canada.,Nova Scotia Health Authority, Halifax, Canada
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15
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Abstract
OBJECTIVE This study estimated the potential loss of life and the lifetime cumulative risk of end-stage renal disease (ESRD) from live kidney donation. DESIGN Markov medical decision analysis. SETTING USA. PARTICIPANTS 40-year-old live kidney donors of both sexes and black/white race. INTERVENTION Live donor nephrectomy. MAIN OUTCOME AND MEASURES Potential remaining life years lost, quality-adjusted life years (QALYs) lost and added lifetime cumulative risk of ESRD from donation. RESULTS Overall 0.532-0.884 remaining life years were lost from donating a kidney. This was equivalent to 1.20%-2.34% of remaining life years (or 0.76%-1.51% remaining QALYs). The risk was higher in male and black individuals. The study showed that 1%-5% of average-age current live kidney donors might develop ESRD as a result of nephrectomy. The added risk of ESRD resulted in a loss of only 0.126-0.344 remaining life years. Most of the loss of life was predicted to be associated with chronic kidney disease (CKD) not ESRD. Most events occurred 25 or more years after donation. Reducing the increased risk of death associated with CKD had a modest overall effect on the per cent loss of remaining life years (0.72%-1.9%) and QALYs (0.58%-1.33%). Smoking and obesity reduced life expectancy and increased overall lifetime risks of ESRD in non-donors. However the percentage loss of remaining life years from donation was not very different in those with or without these risk factors. CONCLUSION Live kidney donation may reduce life expectancy by 0.5-1 year in most donors. The development of ESRD in donors may not be the only measure of risk as most of the predicted loss of life predates ESRD. The study identifies the potential importance of following donors and treating risk factors aggressively to prevent ESRD and to improve donor survival.
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Affiliation(s)
- Bryce A Kiberd
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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16
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Miller AJ, Kiberd BA, Alwayn IP, Odutayo A, Tennankore KK. Donor-Recipient Weight and Sex Mismatch and the Risk of Graft Loss in Renal Transplantation. Clin J Am Soc Nephrol 2017; 12:669-676. [PMID: 28360198 PMCID: PMC5383387 DOI: 10.2215/cjn.07660716] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Accepted: 01/03/2017] [Indexed: 01/23/2023]
Abstract
BACKGROUND AND OBJECTIVES Relatively smaller kidney donor to recipient size is proposed to result in higher graft loss due to nephron underdosing and hyperfiltration injury, but the potentially additive effect of sex and weight mismatch has not been explored in detail. The purpose of this study was to determine if concurrent donor and recipient absolute weight and sex mismatch was associated with graft loss in a cohort of deceased donor kidney transplant recipients. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The association of kidney donor and recipient absolute weight and sex difference with death-censored graft loss was explored using a cohort of United States deceased donor recipients between 2000 and 2014 through the Scientific Registry of Transplants Recipients. Donor-recipient sex pairings (male donor-male recipient; female donor-female recipient; male donor-female recipient; female donor-male recipient) were further stratified by donor and recipient absolute weight difference (>30 or 10-30 kg [donorrecipient] or <10 kg [donor=recipient]) resulting in 20 weight and sex pairings. Time to death-censored graft loss for each pairing was evaluated using multivariable Cox proportional hazards models adjusting for donor, immunologic, surgical, and recipient predictors of graft loss compared with the reference group of male donor-male recipients with no weight mismatch (<10 kg difference). RESULTS Of 115,124 kidney transplant recipients, 21,261 developed death-censored graft failure (median graft survival time was 3.8 years; quartile 1 to 3, 0.0 to 14.8 years). After multivariable adjustment, the highest relative hazards for graft failure were observed for female recipients of male donor kidneys and male recipients of female donor kidneys in situations where the recipient was >30 kg larger than donor (hazard ratio, 1.50; 95% confidence interval, 1.32 to 1.70; hazard ratio, 1.35; 95% confidence interval, 1.25 to 1.45, respectively). CONCLUSIONS A concurrent mismatch in donor-recipient weight (donor
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Affiliation(s)
| | | | - Ian P. Alwayn
- Department of General Surgery, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada; and
| | - Ayo Odutayo
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
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17
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Jaiswal D, Uzans D, Hayden J, Kiberd BA, Tennankore KK. Targeting the Opioid Pathway for Uremic Pruritus: A Systematic Review and Meta-analysis. Can J Kidney Health Dis 2016; 3:2054358116675345. [PMID: 28270926 PMCID: PMC5332085 DOI: 10.1177/2054358116675345] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 09/07/2016] [Indexed: 11/20/2022] Open
Abstract
Background: Patients undergoing hemodialysis or peritoneal dialysis often experience pruritus which is associated with morbidity and mortality. One proposed treatment approach is to target the opioid pathway using either µ-opioid antagonists or κ-opioid agonists. Objective: To review the efficacy of targeting the opioid pathway for pruritus among dialysis patients (uremic pruritus). Design: Systematic review and meta-analysis. Setting/Methods: The systematic review included randomized controlled and randomized crossover trials identified in the MEDLINE, EMBASE, and Cochrane databases (1990 to June 2014) evaluating the efficacy of µ-opioid antagonists or κ-opioid agonists in the treatment of uremic pruritus. Patients: Adult (≥18 years) chronic dialysis patients. Measurements: The primary outcome being evaluated was reduction in itch severity measured on a patient-reported visual analog scale (VAS). Results: Five studies out of 3587 screened articles met the inclusion criteria. Three studies evaluated the efficacy of naltrexone, a µ-opioid antagonist, and 2 studies evaluated the efficacy of nalfurafine, a κ-opioid agonist. Duration of included studies was short, ranging from 2 to 9 weeks. Limitations: Due to the heterogeneity in reporting of outcomes, data from the studies evaluating naltrexone could not be pooled. Pooled analysis, using a random effects model, found that use of nalfurafine resulted in a 9.50 mm (95% confidence interval [CI], 6.27-12.74, P < .001) greater reduction of itch severity (measured on a 100-mm VAS) than placebo in the treatment of uremic pruritus. Conclusions: Nalfurafine holds some promise with respect to the treatment of uremic pruritus among dialysis patients. However, more long-term randomized controlled trials evaluating the efficacy of therapies targeting the opioid pathway for uremic pruritus are required.
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Affiliation(s)
- Deep Jaiswal
- Dalhousie University, Halifax, Nova Scotia, Canada
| | - Drea Uzans
- Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jill Hayden
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Bryce A Kiberd
- Dalhousie University, Halifax, Nova Scotia, Canada; Division of Nephrology, Department of Medicine, Nova Scotia Health, Halifax, Canada
| | - Karthik K Tennankore
- Dalhousie University, Halifax, Nova Scotia, Canada; Division of Nephrology, Department of Medicine, Nova Scotia Health, Halifax, Canada
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18
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Kiberd BA, Miller A, Martin S, Tennankore KK. De Novo Donor-Specific Human Leukocyte Antigen Antibody Screening in Kidney Transplant Recipients After the First Year Posttransplantation: A Medical Decision Analysis. Am J Transplant 2016; 16:3212-3219. [PMID: 27106124 DOI: 10.1111/ajt.13838] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 03/24/2016] [Accepted: 04/14/2016] [Indexed: 01/25/2023]
Abstract
Screening for de novo donor-specific antibodies (dnDSA) in stable kidney transplant recipients is routine practice in some centers. Patients with DSA are at increased risk of graft loss and early intervention may improve outcomes. However, the costs and benefits of dnDSA surveillance are unknown. A medical decision analysis to examine a screening strategy was developed for kidney transplant recipients who had stable graft function and were DSA negative 1 year posttransplant. In the base case, a modest 25% reduction in graft loss in dnDSA-positive patients treated with increased immunosuppression resulted in 0.04618 quality-adjusted years (QALYs) gained. However, benefits from reduced graft loss were eliminated if there was a small increased risk of death from added therapy. The incremental cost effectiveness was marginal at approximately $120 000-250 000 per QALY, but could be more or less favorable depending on several key variables such as efficacy of treatment, screening costs, incidence rate of subclinical dnDSA, and patient survival. Screening performed the best in patients with lower mortality rates and higher baseline incidence rates of dnDSA. Further study is warranted to gather the necessary high-quality evidence to justify screening.
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Affiliation(s)
- B A Kiberd
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.
| | - A Miller
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - S Martin
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - K K Tennankore
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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19
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Tennankore KK, Kim SJ, Alwayn I, Kiberd BA. The Authors Reply. Kidney Int 2016; 90:227. [PMID: 27312454 DOI: 10.1016/j.kint.2016.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 03/24/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Karthik K Tennankore
- Department of Medicine, Division of Nephrology, Dalhousie University, Halifax, Nova Scotia, Canada; Nova Scotia Health Authority, Halifax, Nova Scotia, Canada.
| | - S Joseph Kim
- Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Ian Alwayn
- Department of Surgery, Multi-Organ Transplant Program, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Bryce A Kiberd
- Department of Medicine, Division of Nephrology, Dalhousie University, Halifax, Nova Scotia, Canada; Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
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Tennankore KK, Kim SJ, Alwayn IPJ, Kiberd BA. Prolonged warm ischemia time is associated with graft failure and mortality after kidney transplantation. Kidney Int 2015; 89:648-58. [PMID: 26880458 DOI: 10.1016/j.kint.2015.09.002] [Citation(s) in RCA: 102] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 09/17/2015] [Accepted: 09/24/2015] [Indexed: 11/29/2022]
Abstract
Warm ischemia time is a potentially modifiable insult to transplanted kidneys, but little is known about its effect on long-term outcomes. Here we conducted a study of United States kidney transplant recipients (years 2000-2013) to determine the association between warm ischemia time (the time from organ removal from cold storage to reperfusion with warm blood) and death/graft failure. Times under 10 minutes were potentially attributed to coding error. Therefore, the 10-to-under-20-minute interval was chosen as the reference group. The primary outcome was mortality and graft failure (return to chronic dialysis or preemptive retransplantation) adjusted for recipient, donor, immunologic, and surgical factors. The study included 131,677 patients with 35,901 events. Relative to the reference patients, times of 10 to under 20, 20 to under 30, 30 to under 40, 40 to under 50, 50 to under 60, and 60 and more minutes were associated with hazard ratios of 1.07 (95% confidence interval, 0.99-1.15), 1.13 (1.06-1.22), 1.17 (1.09-1.26), 1.20 (1.12-1.30), and 1.23 (1.15-1.33) for the composite event, respectively. Association between prolonged warm ischemia time and death/graft failure persisted after stratification by donor type (living vs. deceased donor) and delayed graft function status. Thus, warm ischemia time is associated with adverse long-term patient and graft survival after kidney transplantation. Identifying strategies to reduce warm ischemia time is an important consideration for future study.
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Affiliation(s)
- Karthik K Tennankore
- Department of Medicine (Division of Nephrology), Dalhousie University, Halifax, Nova Scotia, Canada; Nova Scotia Health Authority, Halifax, Nova Scotia, Canada.
| | - S Joseph Kim
- Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Ian P J Alwayn
- Department of Surgery, Multi-Organ Transplant Program, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Bryce A Kiberd
- Department of Medicine (Division of Nephrology), Dalhousie University, Halifax, Nova Scotia, Canada; Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
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Panek R, Tennankore KK, Kiberd BA. Incidence, etiology, and significance of acute kidney injury in the early post-kidney transplant period. Clin Transplant 2015; 30:66-70. [PMID: 26497636 DOI: 10.1111/ctr.12660] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2015] [Indexed: 11/28/2022]
Abstract
Little is known about the incidence, causes, and significance of acute kidney injury (AKI) in the early transplant period. This study used a definition as >26 μmol/L increase in creatinine within 48 h or >50% increase over a period >48 h. In 326 adult consecutive recipients of a solitary kidney transplant from 2006 to 2014 followed at this center, 21% developed AKI within the first six months. Most etiologies were CNI toxicity (33%) or unknown (26%), whereas acute rejection accounted for 17% and urinary tract obstruction for 10%. Those with AKI had a significantly lower glomerular filtration rate (GFR) at one-yr post-transplant (adjusted beta coefficient -5.5 mL/min/1.73 m(2) , 95% CI: -10.4, -0.7, p = 0.025) in a multivariable linear regression model. However, the AKI definition missed 6 of 19 episodes of acute rejection and 4 of 10 episodes of urinary tract obstruction. When acute rejection (including those that did not satisfy AKI criteria) was included in the model, other causes of AKI were not significantly associated with GFR at year 1. Although AKI, using current criteria, is likely to be a significant predictor of later outcomes, important causes are missed and the criteria are not sensitive for clinical decision-making.
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Affiliation(s)
- Romuald Panek
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | | | - Bryce A Kiberd
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
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Gomez AT, Kiberd BA, Royston JP, Alfaadhel T, Soroka SD, Hemmelgarn BR, Tennankore KK. Comorbidity burden at dialysis initiation and mortality: A cohort study. Can J Kidney Health Dis 2015; 2:34. [PMID: 26351568 PMCID: PMC4562341 DOI: 10.1186/s40697-015-0068-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 07/24/2015] [Indexed: 11/14/2022] Open
Abstract
Background A high level of comorbidity at dialysis initiation is associated with an increased risk of death. However, contemporary assessments of the validity and prognostic value of comorbidity indices are lacking. Objectives To assess the validity of two comorbidity indices and to determine if a high degree of comorbidity is associated with mortality among dialysis patients. Design Cohort study. Setting QEII Health Sciences Centre (Halifax, Nova Scotia, Canada). Patients Incident, chronic dialysis patients between 01 Jan 2006 and 01 Jul 2013. Measurements Exposure: The Charlson Comorbidity Index (CCI) and End-Stage Renal Disease Comorbidity Index (ESRD-CI) were used to classify individual comorbid conditions into an overall score. Comorbidities were classified using patient charts and electronic records. Outcome: All-cause mortality. Confounders: Patient demographics, dialysis access, cause of ESRD and baseline laboratory data. Methods Regression coefficients were estimated on the CCI and ESRD-CI. Discrimination for death was assessed using Harrell’s c-index. Adjusted Cox proportional hazard models were used to calculate relative hazards and 95 % confidence intervals for each category of the CCI and ESRD-CI. Results The cohort consisted of 771 ESRD patients from 01 Jan 2006 to 01 Jul 2013. Most were male (62 %) and Caucasian (91 %). The cohort had a high proportion of diabetes (48 %), history of previous myocardial infarction (31 %) and heart failure (22 %). Regression coefficients on the CCI and ESRD-CI were 0.55 and 0.52, respectively. The c-index, for the prediction of death, was 0.61 for the CCI and 0.63 for the ESRD-CI. ESRD-CI scores of 4, 5 and ≥6 were associated with a similar mortality risk (adjusted relative hazard of 1.95, 1.89 and 1.99, respectively). There was a small increased mortality risk for CCI scores of 4, 5 and ≥6 (adjusted relative hazard of 1.86, 2.38 and 2.71, respectively). Limitations Classification of comorbidities for each patient was determined by clinical impression. Conclusions The CCI and ESRD-CI have a limited ability to discriminate mortality risk for incident dialysis patients. Acknowledging the frequency with which they are used, this study emphasizes the need to re-examine the usefulness of previously derived comorbidity indices in contemporary dialysis cohorts.
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Affiliation(s)
- Alwyn T Gomez
- Faculty of Medicine, Dalhousie University, Halifax, NS Canada
| | - Bryce A Kiberd
- Department of Medicine (Division of Nephrology), Dalhousie University, Halifax, NS Canada ; Nova Scotia Health Authority, 5820 University Avenue, Halifax, NS Canada B3H 1V8
| | | | - Talal Alfaadhel
- Department of Medicine (Division of Nephrology), Dalhousie University, Halifax, NS Canada
| | - Steven D Soroka
- Department of Medicine (Division of Nephrology), Dalhousie University, Halifax, NS Canada ; Nova Scotia Health Authority, 5820 University Avenue, Halifax, NS Canada B3H 1V8
| | - Brenda R Hemmelgarn
- Department of Medicine, University of Calgary, Calgary, AB Canada ; Department of Community Health Sciences, University of Calgary, Calgary, AB Canada
| | - Karthik K Tennankore
- Department of Medicine (Division of Nephrology), Dalhousie University, Halifax, NS Canada ; Nova Scotia Health Authority, 5820 University Avenue, Halifax, NS Canada B3H 1V8
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Abstract
Background Determining eligibility for a kidney transplant is an important decision. Practice guidelines define contraindications to transplantation; however many are not evidence based. Canadian guidelines recommend that patients unlikely to survive the wait period not be evaluated. The purpose of this study was to evaluate what proportion of patients with a contraindication would survive the wait time. Methods Consecutive incident dialysis patients (January 2006 to December 2012) with a contraindication, defined using Canadian guidelines, were studied. Mortality rates were determined for each individual contraindication. Theoretical survival to the median wait time to transplantation was calculated. Results Of 746 incident patients, 435 (58 %) were deemed to have a contraindication at dialysis start. Nearly 80 % had a contraindication with a high mortality rate (dementia, multisystem disease, etc.). Patients with high mortality rates were less likely to survive the wait list than be transplanted. Patients with non-adherence, obesity, and potentially reversible disease had relatively low mortality rates, were more likely to survive, and possibly be transplanted at a time with the prospect of a better outcome. Conclusions This study gives some credence that many patients with a contraindication are not likely to benefit. A better framework of defining contraindications is needed to allow better decision-making.
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Affiliation(s)
- Bryce A Kiberd
- Department of Medicine, Dalhousie University, Queen Elizabeth II Health Sciences-VG Site, Room 5082 Dickson Building, 5820 University Avenue, Halifax, B3H 1V8 NS Canada
| | - Meteb M AlBugami
- Multiorgan Transplant Center, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Romuald Panek
- Department of Medicine, Dalhousie University, Queen Elizabeth II Health Sciences-VG Site, Room 5082 Dickson Building, 5820 University Avenue, Halifax, B3H 1V8 NS Canada
| | - Karthik Tennankore
- Department of Medicine, Dalhousie University, Queen Elizabeth II Health Sciences-VG Site, Room 5082 Dickson Building, 5820 University Avenue, Halifax, B3H 1V8 NS Canada
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Kiberd BA, Tennankore KK, Daley CJA. Increases in intravenous magnesium use among hospitalized patients: an institution cross-sectional experience. Can J Kidney Health Dis 2015; 2:24. [PMID: 26106483 PMCID: PMC4477498 DOI: 10.1186/s40697-015-0056-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 05/13/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Among hospitalized patients, indications for the measurement of magnesium levels and treatment of hypomagnesemia with intravenous magnesium are not well defined. Recently, there have been reports of worldwide shortages of intravenous magnesium sulphate. OBJECTIVE To examine secular trends in the administration of intravenous magnesium on hospital wards at a tertiary care institution. The secondary objective is to identify factors associated with magnesium use among admitted patients. METHODS Retrospective cross-section review of hospitalized patients at a single Canadian tertiary care center. Utilization of non-parental nutrition intravenous magnesium from 2003 to 2013 stratified by hospital ward was examined. In addition, patient level data from select wards (including medical and surgical services) was examined at early and more recent time period (4/2006 versus 4/2013). RESULTS Among the 248,329 hospitalized patients, intravenous magnesium use increased by 2.86 fold from 2003 to 2013. Not all wards had an increase whereas some had nearly a 10 fold increase in use. In the sample (n = 769), (adjusting for admission magnesium level, presence of an indication for intravenous magnesium, ward location, comorbidity and demographics) intravenous magnesium administration was higher (25.8 % versus 5.5 %) in 2013 versus 2006 (OR 13.91 (95 % CI, 6.21-31.17, p < 0.001). Despite this increase in intravenous magnesium administration, <3 % of patients were admitted on oral magnesium in 2006 and 2013. For patients receiving intravenous magnesium only a minority were discharged on oral therapy despite low levels. CONCLUSIONS This center has witnessed a considerable increase in the use of in-hospital intravenous magnesium over the last 6 years that cannot be explained for by medical indications. The risks and benefits of this therapy deserve further study. If this change in practice is representative of other North American hospitals, it may be responsible for recent drug shortages.
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Affiliation(s)
- Bryce A Kiberd
- Department of Medicine, Dalhousie University, Queen Elizabeth II Health Sciences-VG Site, Room 5082 Dickson Building, 5820 University Avenue, Halifax, Nova Scotia B3H 1V8 Canada
| | - Karthik K Tennankore
- Department of Medicine, Dalhousie University, Queen Elizabeth II Health Sciences-VG Site, Room 5070 Dickson Building, 5820 University Avenue, Halifax, Nova Scotia B3H 1V8 Canada
| | - Christopher J A Daley
- Pharm D. College of Pharmacy, Dalhousie University, Queen Elizabeth II Health Sciences-VG Site, Room 2043, 1276 South Park Street, Halifax, Nova Scotia B3H 2Y9 Canada
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Alfaadhel TA, Soroka SD, Kiberd BA, Landry D, Moorhouse P, Tennankore KK. Frailty and mortality in dialysis: evaluation of a clinical frailty scale. Clin J Am Soc Nephrol 2015; 10:832-40. [PMID: 25739851 DOI: 10.2215/cjn.07760814] [Citation(s) in RCA: 128] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Accepted: 01/12/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVES Frailty is associated with poor outcomes for patients on dialysis; however, previous studies have not taken into account the severity of frailty as a predictor of outcomes. The purpose of this study was to assess if there was an association between the degree of frailty and mortality among patients on incident dialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A cohort study of incident chronic dialysis patients was conducted between January of 2009 and June of 2013 (last follow-up in December of 2013). On the basis of overall clinical impression, the Clinical Frailty Scale (CFS) score was determined for patients at the start of dialysis by their primary nephrologist. This simple scale allocates a single point to different states of frailty (1, very fit; 2, well; 3, managing well; 4, vulnerable; 5, mildly frail; 6, moderately frail; 7, severely frail or terminally ill) with an emphasis on function of the assessed individual. The primary outcome was time to death. Patients were censored at the time of transplantation. RESULTS The cohort consisted of 390 patients with completed CFS scores (mean age of 63±15 years old). Most were Caucasian (89%) and men (67%), and 30% of patients had ESRD caused by diabetic nephropathy. The median Charlson Comorbidity Index score was 4 (interquartile range =3-6), and the median CFS score was 4 (interquartile range =2-5). There were 96 deaths over 750 patient-years at risk. In an adjusted Cox survival analysis, the hazard ratio associated with each 1-point increase in the CFS was 1.22 (95% confidence interval, 1.04 to 1.43; P=0.02). CONCLUSIONS A higher severity of frailty (as defined by the CFS) at dialysis initiation is associated with higher mortality.
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Affiliation(s)
| | | | | | | | - Paige Moorhouse
- Geriatric Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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Kiberd BA, Tennankore KK, West K. Eligibility for the kidney transplant wait list: a model for conceptualizing patient risk. Transplant Res 2014; 3:2. [PMID: 24401550 PMCID: PMC3895784 DOI: 10.1186/2047-1440-3-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Accepted: 12/20/2013] [Indexed: 12/03/2022] Open
Abstract
Background Determining eligibility for a kidney transplant is one of the most important decisions facing nephrologists. It is assumed that the harm of kidney transplantation is minimal and most will benefit. The purpose of this study was to quantify the probability of ‘no benefit’ as defined by death on the wait list; ‘harm’, defined by the probability that a transplanted patient would live less than the average wait listed patient; and ‘benefit’ for the probability a transplanted patient would outlive the average wait listed patient. Methods A computerized model was developed to replicate observed patient survival outcomes in deceased donor kidney transplantation. Three sequential periods of risk for the transplanted recipient compared to the wait listed cohort (increased, equivalent and reduced risk) were modeled. Results The model predicted that wait listed patients with a baseline mortality of 28 deaths per 100 patient years were equally likely to benefit or be harmed with a transplant. However if 20% of patients on the wait list were on hold (assuming a 2.2-fold higher mortality than those who were transplanted), then the baseline mortality rate for equal harm or benefit decreases to 22 deaths per 100 patient years (equivalent life expectancy 4.5 years). Conclusion Patients with limited life expectancies are more likely to suffer some harm than derive benefit from kidney transplantation.
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Affiliation(s)
- Bryce A Kiberd
- Division of Nephrology, Department of Medicine, Dalhousie University, Room 5082 Dickson Building, Queen Elizabeth II HSC-VG site, 5280 University Avenue, Halifax B3H 1V8, NS, Canada.
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Kiberd BA. Death, Taxes, and Now CKD. Am J Kidney Dis 2013; 62:220-2. [DOI: 10.1053/j.ajkd.2013.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Accepted: 05/10/2013] [Indexed: 11/11/2022]
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Marzouk K, Lawen J, Alwayn I, Kiberd BA. The impact of vascular anastomosis time on early kidney transplant outcomes. Transplant Res 2013; 2:8. [PMID: 23675703 PMCID: PMC3662631 DOI: 10.1186/2047-1440-2-8] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Accepted: 05/04/2013] [Indexed: 02/08/2023] Open
Abstract
Background Most studies have found cold ischemic time to be an important predictor of delayed graft function in kidney transplantation. Relatively less is known about the warm time associated with vascular anastomosis and early outcomes. Methods A retrospective cohort of 298 consecutive solitary deceased donor kidney recipients from January 2006 to August 2012 was analyzed to examine the association between anastomosis time and delayed graft function (need for dialysis) and length of hospital stay. Results Delayed graft function (DGF) was observed in 56 patients (18.8%). The median anastomosis time was 30 minutes (interquartile range 24, 45 minutes). Anastomosis time was independently associated with DGF in a multivariable, binary logistic regression analysis (odds Ratio (OR) 1.037 per minute, 95% CI 1.016, 1.057, P = 0.001). An anastomosis time >29 minutes was also associated with a 3.5 fold higher (OR 3.5, 95% CI 1.6, 7.3, P = 0.001) risk of DGF. Median days in hospital was 9 (interquartile range 7, 14 days). Every 5 minutes of longer anastomosis time (0.20 days per minute, 95% CI 0.13, 0.27, P <0.001) was associated with 1 extra day in hospital in a multivariable linear regression model. An anastomosis time >29 minutes was associated with 3.8 (95% CI 1.6, 6.0, P <0.001) more days in hospital. Conclusion Anastomosis time may be an underappreciated but modifiable variable in dictating use of hospital resources. The impact of anastomosis time on longer term outcomes deserves further study.
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Affiliation(s)
- Karim Marzouk
- Department of Medicine, Dalhousie University, 5082 Dickson Building, Queen Elizabeth Health Sciences-VG site, 5280 University Ave, Halifax NS B3H 1V7, Canada.
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Abstract
BACKGROUND Given the unpredictable timing of deceased donor organs and the need for blood transfusion, this study was carried out to determine the rate and risk factors for transfusion in order to identifying a low-risk cohort in the face of a critical blood shortage. METHODS This retrospective chart review examined 306 consecutive deceased solitary kidney transplant recipients from January 2006 to August 2012. RESULTS Records show that 80 (26.1%) patients were transfused with a total of 300 units (0.98 units/transplant) during their first hospital stay. Transfusions were higher in patients on warfarin (8/14, 57%, 5.1 units/transplant) and antiplatelet agents (46/136, 33.8%, 1.1 unit/transplant) compared to no anticoagulants (74/156, 16.7%, 0.47 units/transplant). In a multivariable logistic regression analysis warfarin (odd ratio (OR) 8.2, 95% confidence interval (CI) 2.5-27, P=0.001), antiplatelet agents (OR 2.9, 95% CI 1.6-5.3, P=0.001), recipient age ≥55 years (OR 2.2, 95% CI 1.2-3.9, P=0.008), recipient male (OR 0.36, 95% CI 0.2-0.64, P=0.001) and preop hemoglobin ≥115 g/L (OR 0.32, 95% CI 0.18-0.57, P<0.001) were independent predictors of blood transfusion. Lower bleeding cohorts with transfusion rates <5% could not be identified. CONCLUSION The need for blood is significantly higher in subjects on either warfarin or antiplatelet agents. These patients might be avoided if kidney transplantation is to occur during a critical blood shortage. Unfortunately even patients not on anticoagulation are at some risk.
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Affiliation(s)
- Karim Marzouk
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.
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Kiberd BA. Estimating the long term impact of kidney donation on life expectancy and end stage renal disease. Transplant Res 2013; 2:2. [PMID: 23414596 PMCID: PMC3577426 DOI: 10.1186/2047-1440-2-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2012] [Accepted: 01/30/2013] [Indexed: 11/10/2022] Open
Abstract
Background Long term studies of live kidney donation do not show evidence of appreciable risks to the donor. However nephrectomy reduces total glomerular filtration rates (GFR) and is associated with increased rates of proteinuria and possibly hypertension. It is not clear to what extent these changes are associated with reduced life expectancy (LE) or increased risk of end stage renal disease (ESRD) since follow up is incomplete in most reports. Methods In a computer simulation model based on a US population chronic kidney disease model, increased hazard rates for higher blood pressure, proteinuria and low GFR were applied to healthy individuals undergoing donor nephrectomy. Subsequent LE and cumulative risk of ESRD were calculated. Results Kidney donation is projected to reduce LE by 0.83 years and increase the absolute cumulative risk of ESRD by 0.89% for a 40-year-old white male. White females were predicted to have slightly greater loss of life and less added ESRD risk. Conversely, Blacks have greater risks of ESRD after donation. Older donors with hypertension were predicted to lose less life years and lower cumulative ESRD risks than young donors. Despite these increased risks most donors will have better life expectancy and lower ESRD rates than the general population since they are a highly selected cohort. Conclusions This study attempts to quantify increases in death and ESRD from donor nephrectomy assuming the risk factors of hypertension, low GFR and proteinuria have the same significance in this population as in the general population. Further study is required to better estimate the risks of donation and test whether these assumptions are valid.
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Affiliation(s)
- Bryce A Kiberd
- Department of Medicine, Dalhousie University, Halifax, 5082 Dickson Building, Queen Elizabeth II HSC VG site, University Ave, Nova Scotia, B3H 1V8, Canada.
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Albugami MM, Panek R, Soroka S, Tennankore K, Kiberd BA. Access to kidney transplantation: outcomes of the non-referred. Transplant Res 2012; 1:22. [PMID: 23369260 PMCID: PMC3561041 DOI: 10.1186/2047-1440-1-22] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Accepted: 09/18/2012] [Indexed: 11/10/2022] Open
Abstract
UNLABELLED BACKGROUND There is a concern that some, especially older people, are not referred and could benefit from transplantation. METHODS We retrospectively examined consecutive incident end stage renal disease (ESRD) patients at our center from January 2006 to December 2009. At ESRD start, patients were classified into those with or without contraindications using Canadian eligibility criteria. Based on referral for transplantation, patients were grouped as CANDIDATE (no contraindication and referred), NEITHER (no contraindication and not referred) and CONTRAINDICATION. The Charlson Comorbidity Index (CCI) was used to assess comorbidity burden. RESULTS Of the 437 patients, 133 (30.4%) were CANDIDATE (mean age 50 and CCI 3.0), 59 (13.5%) were NEITHER (age 76 and CCI 4.4), and 245 (56.1%) were CONTRAINDICATION (age 65 and CCI 5.5). Age was the best discriminator between NEITHER and CANDIDATES (c-statistic 0.96, P <0.0001) with CCI being less discriminative (0.692, P <0.001). CANDIDATES had excellent survival whereas those patients designated NEITHER and CONTRAINDICATION had high mortality rates. NEITHER patients died or developed a contraindication at very high rates. By 1.5 years 50% of the NEITHER patients were no longer eligible for a transplant. CONCLUSIONS There exists a relatively small population of incident patients not referred who have no contraindications. These are older patients with significant comorbidity who have a small window of opportunity for kidney transplantation.
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Affiliation(s)
- Meteb M Albugami
- Department of Medicine, Dalhousie University, Halifax, NS, Canada 5820 University Avenue, Halifax, NS, B3H 1V8, Canada.
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Tennankore KK, Soroka SD, Kiberd BA. The impact of an "acute dialysis start" on the mortality attributed to the use of central venous catheters: a retrospective cohort study. BMC Nephrol 2012; 13:72. [PMID: 22846341 PMCID: PMC3470959 DOI: 10.1186/1471-2369-13-72] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Accepted: 07/11/2012] [Indexed: 12/02/2022] Open
Abstract
Background Central venous catheters (CVCs) are associated with early mortality in dialysis patients. However, some patients progress to end stage renal disease after an acute illness, prior to reaching an estimated glomerular filtration rate (eGFR) at which one would expect to establish alternative access (fistula/peritoneal dialysis catheter). The purpose of this study was to determine if exclusion of this “acute start” patient group alters the association between CVCs and mortality. Methods We conducted a retrospective cohort study of 406 incident dialysis patients from 1 Jan 2006 to 31 Dec 2009. Patients were classified as acute starts if 1) the eGFR was >25 ml/min/1.73 m2, ≤3 months prior to dialysis initiation and declined after an acute event (n = 45), or 2) in those without prior eGFR measurements, there was no supporting evidence of chronic kidney disease on history or imaging (n = 12). Remaining patients were classified as chronic start (n = 349). Results 98 % and 52 % of acute and chronic starts initiated dialysis with a CVC. There were 148 deaths. The adjusted mortality hazard ratio (HR) for acute vs. chronic start patients was 1.84, (95 % CI [1.19-2.85]). The adjusted mortality HR for patients dialyzing with a CVC compared to alternative access was 1.19 (95 % CI [0.80-1.77]). After excluding acute start patients, the adjusted HR fell to 1.03 (95 % CI [0.67-1.57]). Conclusions A significant proportion of early dialysis mortality occurs after an acute start. Exclusion of this population attenuates the mortality risk associated with CVCs.
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Affiliation(s)
- Karthik K Tennankore
- Department of Medicine, Division of Nephrology, University of Toronto, University Health Network/Toronto General Hospital, 21 Carlton Street, Unit 1405, Toronto, ON, Canada.
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Abstract
Background There is a perception that kidney transplant recipients transferred from pediatric centers to adult care have an increased risk of graft loss. It is not clear whether young adults transplanted in adult centers also suffer from high graft loss rates. Methods We examined death censored graft survival in 3 cohorts of young patients transplanted at a single center. Pediatric (PED) patients transplanted at the pediatric center were compared to a cohort of young adults (YAD; age 18- < 25) and a cohort of adults (ADL; age 25-35). Results In a multivariate Cox model for death-censored graft survival, PED survival was statistically similar to the YAD (HR 0.86, 95% CI 0.44, 1.7, p = 0.66), however the ADL cohort (HR 0.45, 95% CI 0.25, 0.82, p = 0.009) demonstrated better survival. Admitted non-adherence rates were not different among cohorts. Patients were transferred within a narrow age window (18.6 ± 1.0 age in years) but at a wide range of times from the date of transplantation (5.1 ± 3.5 years) and with a wide range of graft function (serum creatinine 182 ± 81 μmol/L). Conclusions The perception that pediatric transfers do poorly reflects advanced graft dysfunction in some at the time of transfer. The evidence also suggests that it is not the transfer of care that is the critical issue but rather recipients, somewhere between the ages of 11-14 and 25, are a unique and vulnerable cohort. Effective strategies to improve outcomes across this age group need to be identified and applied consistently.
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Affiliation(s)
- James A Kiberd
- Department of Medicine and Pediatrics, Dalhousie Medical School, Halifax, Nova Scotia, Canada
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Tennankore KK, Soroka SD, West KA, Kiberd BA. Macrocytosis may be associated with mortality in chronic hemodialysis patients: a prospective study. BMC Nephrol 2011; 12:19. [PMID: 21569355 PMCID: PMC3114714 DOI: 10.1186/1471-2369-12-19] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Accepted: 05/11/2011] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Macrocytosis occurs in chronic hemodialysis (CHD) patients; however, its significance is unknown. The purpose of this study was to establish the prevalence and distribution of macrocytosis, to identify its clinical associations and to determine if macrocytosis is associated with mortality in stable, chronic hemodialysis patients. METHODS We conducted a single-centre prospective cohort study of 150 stable, adult CHD patients followed for nine months. Macrocytosis was defined as a mean corpuscular volume (MCV) > 97 fl. We analyzed MCV as a continuous variable, in tertiles and using a cutoff point of 102 fl. RESULTS The mean MCV was 99.1 ± 6.4 fl, (range 66-120 fl). MCV was normally distributed. 92 (61%) of patients had an MCV > 97 fl and 45 (30%) > 102 fl. Patients were not B12 or folate deficient in those with available data and three patients with an MCV > 102 fl had hypothyroidism. In a logistic regression analysis, an MCV > 102 fl was associated with a higher Charlson-Age Comorbidity Index (CACI) and higher ratios of darbepoetin alfa to hemoglobin (Hb), [(weekly darbepoetin alfa dose in micrograms per kg body weight / Hb in g/L)*1000]. There were 23 deaths at nine months in this study. Unadjusted MCV > 102 fl was associated with mortality (HR 3.24, 95% CI 1.42-7.39, P = 0.005). Adjusting for the CACI, an MCV > 102 fl was still associated with mortality (HR 2.47, 95% CI 1.07-5.71, P = 0.035). CONCLUSIONS Macrocytosis may be associated with mortality in stable, chronic hemodialysis patients. Future studies will need to be conducted to confirm this finding.
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Affiliation(s)
- Karthik K Tennankore
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Steven D Soroka
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Kenneth A West
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Bryce A Kiberd
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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Abstract
BACKGROUND Proteinuria is a predictor of graft loss and death in kidney transplant recipients. This study examines the clinical significance of albumin-to-creatinine (ACR) and protein-to-creatinine (PCR) ratios compared with conventional dipstick measures of proteinuria. METHODS At this single centre, 500 adult patients with a functioning kidney transplant > 4 months provided a urine sample for dipstick, ACR and PCR. The primary end point was defined as death-censored graft loss. Associations between proteinuria and graft loss were examined by concordance statistics and multivariate Cox models. RESULTS There were 32 graft losses over a mean 2.98 years follow-up. PCR (c = 0.82, P < 0.001) and ACR (c = 0.83, P < 0.001) demonstrated similar concordance with events, and both scored higher than dipstick (c = 0.76, P < 0.001). ACR cut points of 30 and 300 mg/g for grading albuminuria were equivalent to 130 and 490 mg/g for PCR. Moderate grades of proteinuria by ACR and PCR were predicted of adverse events in a multivariate analysis. CONCLUSIONS ACR and PCR are probably equivalent in predicting adverse events. Conventional dipstick is also predictive but does not appear to be as sensitive.
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Affiliation(s)
- Romuald Panek
- Department of Medicine, Dalhousie University, Halifax, Canada
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Gourishankar S, Houde I, Keown PA, Landsberg D, Cardella CJ, Barama AA, Dandavino R, Shoker A, Pirc L, Wrobel MM, Kiberd BA. The CLEAR study: a 5-day, 3-g loading dose of mycophenolate mofetil versus standard 2-g dosing in renal transplantation. Clin J Am Soc Nephrol 2010; 5:1282-9. [PMID: 20498245 DOI: 10.2215/cjn.09091209] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Adequate early mycophenolic acid (MPA) exposure is associated with lower rates of acute rejection in renal transplantation. The aim of this randomized controlled trial was to determine if higher initial mycophenolate mofetil (MMF) doses increased the proportion of patients reaching therapeutic MPA levels (30 to 60 mg.h/L) by day 5. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS De novo renal transplant patients were randomized to receive intensified dosing of MMF (1.5 g twice daily on days 1 to 5, then 1.0 g twice daily) or standard dosing (1.0 g twice daily). All recipients received tacrolimus and prednisone. Full MPA areas under the curve (AUCs) were completed on days 3 and 5, whereas a limited sampling strategy was utilized at four subsequent time points. RESULTS At day 5, 47.5% of the MMF 3-g arm achieved the MPA therapeutic window versus 54.4% of the MMF 2-g arm. However, MPA AUC levels were significantly higher in the 3-g arm at day 3 and 5. This resulted in a trend for fewer treated acute rejections at 6 months. Significantly more acute rejections (treated, biopsy-proven including and excluding borderline) occurred in patients with MPA AUC levels<30 mg.h/L compared with those >or=30 mg.h/L at day 5. No significant differences were seen in common adverse events. CONCLUSIONS A limited intensified dose of MMF increased early MPA exposure and was well tolerated. Further studies are required to determine whether limited intensified MMF dosing can reduce acute rejection.
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Abstract
Polyoma virus nephropathy is an important cause of graft dysfunction in kidney transplant recipients and screening to prevent disease has been advocated. Although screening incurs new costs, our hypothesis is that savings from less immunosuppression in those with positive screening tests could pay for overall costs of screening. In 134 consecutive recipients, polyoma virus (positive decoy cells) was detected in the urine of 34 (25.4%) individuals over a 2-year follow-up. Of these 34, 11 had a plasma BK PCR of >7700 copies/mL. Immunosuppression was reduced stepwise in these patients until viral loads fell <1000/mL. Overall screening costs (including extra plasma PCR testing) were estimated at $33,450. Those with positive PCR had greater reductions in annual immunosuppression costs by year 2 ($6452 vs. $2799, p = 0.0015) compared to those with negative screens. At the end of the 2-year period, 61% of the screening costs were covered by less immunosuppressant costs. At the end of 30 months there were net savings. In summary, reductions in immunosuppression cover the cost of screening for polyoma viral infection. Longer-term follow-up is needed to ensure patient outcomes remain acceptable.
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Affiliation(s)
- F Smith
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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Abstract
Immunosuppression is associated with an increased risk of cancer in kidney transplant recipients compared to the general population. It is less clear whether standardized cancer mortality ratios (SMRs) are also increased. This study's hypothesis is that SMRs are not increased because of competing risks of death. During the median follow-up of 5.05 years (Q1-Q3: 2.36-8.62), there were 1937 cancer deaths and 36 619 noncancer deaths among 164 078 first kidney-only transplant recipients captured in the United States Renal Data System between January 1990 and December 2004. The observed cancer death rate was 206 per 100 000 patient-years compared to an expected rate of 215 per 100,000 patient-years in the general population. The overall age- and sex-adjusted SMR was only 0.96 (95% CI 0.92-1.00). However, patients <50 years had SMRs significantly greater than unity while patients >60 had SMRs lower than unity. Up to 25% of cancer-related deaths occurred after allograft failure. These findings challenge the notion that cancer is a major cause of premature death in all kidney transplant recipients and has implications for design of cancer prevention strategies in kidney transplant recipients.
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Affiliation(s)
- B A Kiberd
- Department of Medicine, Dalhousie University, Halifax Nova Scotia, British Columbia, Canada.
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Abstract
BACKGROUND Erythrocytosis is relatively common post-kidney transplantation and may have adverse consequences. This study examined whether the incidence of erythrocytosis has remained stable over time and explored the impact of this condition on patient outcomes. METHODS This was a retrospective single center review of an incidence cohort (transplanted between 1993 and 2005). Predictors of erythrocytosis and hemoglobin levels and subsequent patient and allograft survival were examined. RESULTS Erythrocytosis (hemoglobin >170 g/L for >1 month) was observed in 59 of 511 recipients. Erythrocytosis developed in only 8.1% of those transplanted from 1997 to 2005, compared with 18.7% in those transplanted from 1993 to 1996 (p = 0.0005). Independent predictive factors were use of angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEi/ARBs) (HR 0.176, 95% CI 0.040-0.71, p = 0.016), male gender (HR 3.72, 95% CI 1.54-9.0, p = 0.003), and mycophenolic acid agents (HR 0.49, 95% CI 0.237-0.99, p = 0.049). Patients with erythrocytosis had superior overall survival (HR for death 0.105, 95% CI 0.014-0.760, p = 0.026) but a trend for worse death censored graft loss (univariate HR 2.06, 95% CI 0.91-4.65, p = 0.084). CONCLUSIONS The incidence of erythrocytosis is falling and is likely related to greater ACEi/ARB use and possibly more antiproliferative immunosuppression. Patient survival is excellent in those with erythrocytosis, but long-term graft survival may be compromised.
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Affiliation(s)
- Bryce A Kiberd
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.
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Abstract
We determined the rate and risk factors for end-stage renal disease (ESRD) in consecutive patients discharged after a cardiac event in a large, unbiased Canadian cohort that receives universal health coverage. A total of 8236 adults hospitalized over a 2 year period were followed for up to 7.5 years and the incidence of ESRD and mortality determined. Of these, 113 reached ESRD (stage 5). Patients with moderate (stage 3) and severe (stage 4) renal insufficiency were more likely to develop ESRD than those patients at stage 1 or 2. However, patients with moderate renal insufficiency were 78.6 times more likely to die than to develop ESRD. Absolute rates of progression to ESRD per 100-patient years were 0.08 at stages 1 and 2, 0.17 at stage 3 and 4.27 at stage 4. Age, diabetes, hypertension and congestive heart failure also predicted ESRD. We found that patients with stage 4 disease are at high risk of ESRD after a cardiac admission while those at stage 3 are far more likely to die than to develop ESRD.
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Abstract
Guidelines recommend that > or =50% of patients starting dialysis have a fistula. We reviewed our experience in consecutive incident patients over a 1-year period. Only 30 of the 93 patients starting hemodialysis had a fistula that was accessed. Late referral (nephrology contact <90 days) was a significant issue in 48% (30/63) of the patients without a fistula. Most (n=21) of the late referrals were acute disease; only 9 were late referrals of chronic disease. Nephrology follow-up exceeded 200 days in the remaining (33/63) without this access. In the cohort with sufficient nephrology referral, we explored variables associated with a fistula (n=30) compared with those without one (n=33). In multivariate logistic regression analysis, peripheral vascular disease (odds ratio [OR] 0.026, 95% confidence interval [CI] 0.002-0.286) and rapid loss of estimated glomerular filtration rate (eGFR) (OR 0.745 per mL/min/1.73 m(2)/year, 95% CI 0.625-0.888) in the year preceding dialysis were significant negative predictors for a fistula. Patients without access experienced faster declines in GFR in the year preceding dialysis (12.1+/-9.9 vs. 4.7+/-3.5 mL/min 1.73 m(2) with access, p<0.001). Glomerular filtration rate loss in the 2 years before starting dialysis was the same between the 2 groups (-0.54+/-10.4 vs. 1.42+/-3.9 mL/min 1.73 m(2)). Age, sex, diabetes, other comorbidity, length of nephrology follow-up, eGFR at dialysis start, hemoglobin, and albumin were not significant. At our center, rapid loss of renal function in otherwise stable chronic kidney disease (CKD) patients is more important than late referral of CKD for the lack of access. Improvements in rapid referral for access creation could help reduce this barrier.
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Affiliation(s)
- Vineet Bhan
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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Clase CM, Kiberd BA, Garg AX. Relationship between Glomerular Filtration Rate and the Prevalence of Metabolic Abnormalities: Results from the Third National Health and Nutrition Examination Survey (NHANES III). ACTA ACUST UNITED AC 2007; 105:c178-84. [PMID: 17347576 DOI: 10.1159/000100489] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2006] [Accepted: 12/11/2006] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND AIMS National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines recommend that all people with a glomerular filtration rate (GFR) <60 ml/min/1.73 m(2) undergo evaluation for anaemia and metabolic bone disease. We aim to report the prevalence of metabolic complications in adults with low GFR. METHODS Analysis of 15,802 non-institutionalised adult participants in the Third National Health and Nutrition Survey (NHANES III), a cross-sectional population-based survey conducted in the United States between 1986 and 1994. Renal function was estimated according the modification of diet in renal disease equation 7 (MDRD GFR), the Cockcroft-Gault formula and by the serum creatinine cut-off points described by Couchoud and colleagues. Haemoglobin <110 g/l occurred in 42.2% [95% confidence interval (CI) 28.3-56.0] of patients with MDRD GFR <30 ml/min/1.73 m(2) [stage 3 chronic kidney disease (CKD)] and 3.5% (95% CI 2.4-4.7) of patients with MDRD GFR between 30 and 60 ml/min/1.73 m(2) (stage 4-5 CKD). Corresponding prevalences for calcium <2.15 mmol/l were 8.2 (95% CI 1.6-14.8) and 3.4 (95% CI 1.7-5.2); for phosphate >1.6 mmol/l, 15.1 (95% CI 5.0-25.3) and 0.3 (95% CI 0-0.6); and for bicarbonate <23 mmol/l, 32.7 (95% CI 19.6-45.9) and 5.7 (95% CI 3.3-8.2), respectively. Similar results were obtained when patients were categorised by the Cockcroft-Gault formula or Couchoud's cut-off points. CONCLUSIONS The prevalence of complications in stage 3 CKD is low. These data do not support the recommendation for routine screening for metabolic complications of renal insufficiency in adults seen in primary care settings whose GFR exceeds 30 ml/min/1.73 m(2).
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Affiliation(s)
- Catherine M Clase
- Department of Medicine, McMaster University, Hamilton, Ont., Canada.
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Foote CJ, Greer W, Kiberd BA, Fraser A, Lawen J, Nashan B, Belitsky P. MDR1 C3435T polymorphisms correlate with cyclosporine levels in de novo renal recipients. Transplant Proc 2007; 38:2847-9. [PMID: 17112845 DOI: 10.1016/j.transproceed.2006.08.120] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2006] [Indexed: 11/23/2022]
Abstract
BACKGROUND Single nucleotide polymorphisms (SNPs) in the multidrug resistance (MDR1) gene correlate with the intestinal function of P-glycoprotein (PGP). PGP serves as a hydrophobic export pump that extrudes cyclosporine (CsA) across the luminal membrane thus preventing CsA absorption. These genetic variants may predict CsA exposure levels in the early posttransplantation period. METHODS CsA absorption profiles were established in 75 renal transplant patients using total daily dose and body weight adjusted 4-hour area under the time-concentration curve, AUC(0-4)/mg dose/kg body weight, on posttransplant day 3. These patients were subsequently genotyped for C3435T and G2677T polymorphisms using real-time polymerase chain reaction. An analysis was conducted to assess the independent impact of C3435T and G2677T SNPs on CsA bioavailability. RESULTS C3435T polymorphisms were found to be an independent predictor of CsA AUC(0-4)/mg dose/kg levels on postoperative day 3. An inverse correlation was found between the number of T alleles and AUC values such that every T allele was associated with an approximate 15% decrement in AUC(0-4)/mg dose/kg (P = .034). A similar nonsignificant trend was observed for G2677T polymorphisms. CONCLUSIONS MDR1 SNPs are correlated with CsA exposure in the early post-transplant period. Polymorphisms, in conjunction with other criteria, may become a useful tool to optimize initial drug dosing in renal transplantation.
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Affiliation(s)
- C J Foote
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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MacAulay J, Thompson K, Kiberd BA, Barnes DC, Peltekian KM. Serum creatinine in patients with advanced liver disease is of limited value for identification of moderate renal dysfunction: are the equations for estimating renal function better? Can J Gastroenterol 2006; 20:521-6. [PMID: 16955148 PMCID: PMC2659934 DOI: 10.1155/2006/858053] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND The Cockcroft-Gault formula (CGF) is used to estimate the glomerular filtration rate (GFR) based on serum creatinine (Cr) levels, age and sex. A new formula developed by the Modification of Diet in Renal Disease (MDRD) Study Group, based on the patient's Cr levels, age, sex, race and serum urea nitrogen and serum albumin levels, has shown to be more accurate. However, the best formula to identify patients with advanced liver disease (ALD) and moderate renal dysfunction (GFR 60 mL/min/1.73 m2 or less) is not known. The aim of the present study was to compare calculations of GFR, using published formulas (excluding those requiring urine collections) with standard radionuclide measurement of GFR in patients with ALD. METHODS Fifty-seven consecutive subjects (40% women) with a mean age of 50 years (range 16 to 67 years) underwent 99m-technetium-diethylenetriamine pentaacetic acid (99mTc-DTPA) (single injection) radionuclide measurement of GFR. To calculate GFR, three formulas were used: the reciprocal of Cr multiplied by 100 (100/Cr), the CGF and the MDRD formulas. Pearson's correlation coefficient (r) and Bland-Altman analyses of agreement were used to analyze the association between 99mTc-DTPA clearance and the three equations for GFR. RESULTS The mean 99mTc-DTPA clearance was 83 mL/min/1.73 m2 (range 28 mL/min/1.73 m2 to 173 mL/min/1.73 m2). Mean calculated GFRs by 100/Cr, the CGF and the MDRD formula were 106 mL/min/1.73 m2, 98 mL/min/1.73 m2 and 86 mL/min/1.73 m2, respectively. Regression analysis showed good correlation between radionuclide GFR and calculated GFR with r(100/Cr)=0.74, r(CGF)=0.80, r(MDRD)=0.87, all at P > or = 0.0001. The MDRD formula provided the least bias. The Bland-Altman plot showed best agreement between GFR calculated by the MDRD formula and 99mTc-DTPA clearance, with only 3 mL/min/1.73 m2 overestimation. There was higher variability between radionuclide GFR and calculated GFR by the CGF and by 100/Cr. Although there was no difference in precision, GFR calculated by the MDRD formula had the best overall accuracy. The sensitivity and specificity for detection of moderate renal dysfunction by the MDRD formulas were 73% and 87%, respectively. CONCLUSIONS Among the Cr-based GFR formulas, the MDRD formula showed a larger proportion of agreement with radionuclide GFR in patients with ALD. In clinical practice, the MDRD is the best formula for detection of moderate renal dysfunction among those with ALD.
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Affiliation(s)
- Jillian MacAulay
- Department of Medicine, Division of Gastroenterology (Hepatology Services), Dalhousie University, Halifax, Nova Scotia
| | - Kara Thompson
- Office of Medical Outcomes Research and Biostatistics, Dalhousie University, Halifax, Nova Scotia
| | - Bryce A Kiberd
- Division of Nephrology, Dalhousie University, Halifax, Nova Scotia
| | - David C Barnes
- Department of Diagnostic Imaging, Division of Nuclear Medicine, Dalhousie University, Halifax, Nova Scotia
| | - Kevork M Peltekian
- Department of Medicine, Division of Gastroenterology (Hepatology Services), Dalhousie University, Halifax, Nova Scotia
- Correspondence and reprints: Dr Kevork M Peltekian, Hepatology Services, 1278 Tower Road, Victoria General Site, Room 6-302, Halifax, Nova Scotia B3H 2Y9. Telephone 902-473-2898, fax 902-473-2783, e-mail
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Abstract
The study explores the prevalence of unrecognized diabetes mellitus (DM), the incidence and risk factors new onset diabetes mellitus (NODM) and determines whether patient survival differs between patients with transient (NODM that resolves) compared with those with fixed NODM. This is a single center review of solitary kidney recipients transplanted from 1993 to 2003. Of the 381 patients without DM pre-transplant, 111 met criteria for DM post. Of these 17 were unrecognized to have DM, 31 had transient (resolved) NODM and 64 had fixed NODM. In a multivariate analysis, age, body mass index, repeat transplant and rejection were risk factors for NODM. In a separate analysis of only fixed NODM, tacrolimus use showed a trend for an independent association (HR 1.7 95% CI 0.95-2.9). NODM patient survival was comparable to non-diabetic recipients even up to 10 yr; however, excess mortality started to be seen in the fixed NODM subgroup at late follow up. Use of more stringent DM criteria results in a population with relatively good intermediate term survival and allows detection and treatment of early disease. Transient NODM represents approximately one third of NODM and has a relatively good prognosis.
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Affiliation(s)
- Mathew Kiberd
- Division of Nephrology, Department of Medicine, Dalhousie University, Halifax Nova Scotia, Canada
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Barber CEH, Hewlett TJC, Geldenhuys L, Kiberd BA, Acott PD, Hatchette TF. BK virus nephropathy in a heart transplant recipient: case report and review of the literature. Transpl Infect Dis 2006; 8:113-21. [PMID: 16734635 DOI: 10.1111/j.1399-3062.2006.00163.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The human polyomavirus BK virus (BKV) remains latent in the urinary tract and may be reactivated in immunocompromised states. BKV is noted to be the etiologic agent of polyomavirus-associated nephropathy (PVAN), which is a significant cause of allograft failure in renal transplant patients. Renal dysfunction following non-renal solid organ transplantation is common and is typically attributed to drug toxicity or patient comorbidities. In this article we describe a case of PVAN in the native kidneys of a heart transplant recipient and review the literature. Although this is only the fourth case reported, BKV nephropathy should be considered in the differential diagnosis of new renal failure following non-kidney solid organ transplantation, as early diagnosis of PVAN is necessary to prevent irreversible renal damage.
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Affiliation(s)
- C E H Barber
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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Kiberd BA. Atorvastatin has no beneficial effect on cardiovascular outcomes in patients with advanced chronic kidney disease. Nat Clin Pract Nephrol 2006; 2:354-5. [PMID: 16932460 DOI: 10.1038/ncpneph0203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2006] [Accepted: 03/22/2006] [Indexed: 05/11/2023]
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48
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Keough-Ryan TM, Kiberd BA, Dipchand CS, Cox JL, Rose CL, Thompson KJ, Clase CM. Outcomes of acute coronary syndrome in a large Canadian cohort: impact of chronic renal insufficiency, cardiac interventions, and anemia. Am J Kidney Dis 2005; 46:845-55. [PMID: 16253724 DOI: 10.1053/j.ajkd.2005.07.043] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2005] [Accepted: 07/19/2005] [Indexed: 01/27/2023]
Abstract
BACKGROUND Chronic renal insufficiency (CRI) has been identified as an important risk factor for cardiac events. Studies in the United States reported decreased survival and decreased use of surgical and medical interventions after myocardial infarction in patients with CRI. METHODS We studied the impact of renal function on health outcomes in a Canadian cohort of consecutive patients admitted with acute coronary syndrome (ACS) between October 1997 and October 1999. The study design is an observational cohort of 5,549 adult patients who survived to discharge with a discharge diagnosis of ACS. Renal function is classified into 4 levels: (1) normal, glomerular filtration rate (GFR) greater than 80 mL/min/1.73 m2 (>1.33 mL/s); (2) mild CRI, GFR of 60 to 80 mL/min/1.73 m2 (1.00 to 1.33 mL/s); (3) moderate CRI, GFR of 30 to 59 mL/min/1.73 m2 (0.50 to 0.98 mL/s); and (4) severe CRI, GFR less than 30 mL/min/1.73 m2 (<0.50 mL/s). The primary outcome is death. RESULTS Advanced and moderate CRI independently predicted death (hazard ratio, 1.06; 95% confidence interval [CI], 1.01 to 1.12; and hazard ratio, 1.23; 95% CI, 1.18 to 1.29). Severe anemia (hemoglobin level < 9.0 g/dL [<90 g/L]) also was an independent risk factor for death (hazard ratio, 1.38; 95% CI, 1.18 to 1.61). Use of beta-blockers (hazard ratio, 0.91; 95% CI, 0.86 to 0.97), acetylsalicylic acid (hazard ratio, 0.90; 95% CI, 0.84 to 0.97), lipid-lowering therapy (hazard ratio, 0.84; 95% CI, 0.78 to 0.89), and medical thrombolysis (hazard ratio, 0.89; 95% CI, 0.81 to 0.97) were associated with reduced risk for death. Medical interventions with beta-blockers, acetylsalicylic acid, lipid-lowering therapy, and thrombolysis and surgical intervention were significantly less likely to be used in patients with CRI. CONCLUSION Despite universal access to health care, Canadian patients with CRI are more likely to die after a cardiac event and less likely to receive important interventions.
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Kiberd BA, Puthenparumpil JJ, Fraser A, Tett SE, Lawen J. Impact of mycophenolate mofetil loading on drug exposure in the early posttransplant period. Transplant Proc 2005; 37:2320-3. [PMID: 15964408 DOI: 10.1016/j.transproceed.2005.03.059] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2004] [Indexed: 10/25/2022]
Abstract
UNLABELLED Achieving adequate therapeutic levels of immunosuppressive medications is important in rejection prevention. This study examined exposure to mycophenolic acid (MPA) in kidney transplant patients within the first 5 days posttransplantation. METHODS This single-center, nonrandomized study of first solitary kidney allograft recipients receiving cyclosporine (n = 116) or tacrolimus (n = 50) included patients who received either 1 g or 1.5 g of mycophenolate mofetil twice daily starting postoperatively. Exposure to MPA was measured at days 3 and 5 posttransplant using published limited sampling time equations. RESULTS There were no significant differences in exposure in the cyclosporine-treated patients receiving 3-g (n = 22) compared to 2-g (n = 94) daily doses (AUC([0-12]) 33.8 +/- 10.0 mg*h/L versus 30.1 +/- 9.7 mg*h/L, P = .20, respectively). About half the patients in both groups had AUC([0-12]) <30 mg*h/L on days 3 and 5 posttransplant. On the other hand, there was significantly greater exposure on day 3 in the tacrolimus-treated patients receiving 3 g (n = 21) compared to 2 g (n = 29) daily (AUC([0-12]) 43.1 +/- 9.0 mg*h/L versus 36.8 +/- 11.1 mg*h/L, P = .016, respectively). On day 3 one (4.8%) patient receiving 3 g had an AUC([0-12]) of <30 mg*h/L; whereas, eight (27.5%) receiving 2 g were below this level (P = .068). The AUC([0-12]) levels were not different on day 5. CONCLUSIONS Loading with higher doses of mycophenolate mofetil results in greater exposure and a trend toward more patients in the therapeutic window within the first week for tacrolimus- but not for cyclosporine-treated patients.
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Affiliation(s)
- B A Kiberd
- Department of Medicine, Dalhousie University, 5082 AC Dickson, Queen Elizabeth II HSC-VG site, Halifax, Nova Scotia B3H 2Y9, Canada
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Abstract
Polyomavirus nephropathy (PVN) is an emerging medical dilemma in kidney transplantation. Methods to screen before clinical disease are available and early immunosuppression reduction may change the natural history of progression. However, the consequences of an increase in rejection may limit the benefits. In a simulation model a 'screen' versus 'no-screen' strategy was compared. Baseline PVN cumulative incidence was assumed to be 4%. Patients with PVN were modeled to have 4-fold higher risk of graft loss. In the screen strategy, patients positive for blood DNA PCR had their immunosuppression reduced. This pre-emptive change was modeled to reduce progression to overt PVN by 80%. Therapy reduction was associated with a 10% risk of precipitating acute rejection and greater risk of chronic allograft loss. In the baseline case, screening saved 1912 dollars (discounted) and produced 0.020 more quality adjusted life years (QALYs) than not screening. Screening resulted in decreased net QALYs if the false positive viremia rate was >9.5% and the PVN incidence was <2.1%. Much of the cost savings of screening relate to savings from immunosuppression reduction in the screened arm. Screening may well be cost-effective if not cost saving in centers with high PVN rates. There remain significant areas of uncertainty.
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Affiliation(s)
- Bryce A Kiberd
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada. bryce.
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