Effect of the use or nonuse of long-term dialysis on the subsequent survival of renal transplants from living donors

Patient and graft survival after pre-emptive versus non-pre-emptive kidney transplantation: a single-center experience from Turkey

OBJECTIVE

We sought to report the graft and patients survival of pre-emptive and non-pre-emptive kidney transplantations performed in our center.

METHODS

The 859 subjects showed a mean age of 36.1 years and included 64.6%; males, who received grafts from living (n = 665) or deceased (n = 194) donors between January 2008 and June 2011. We reviewed their medical records retrospectively, to separately pre-emptive versus non-pre-emptive recipients for year transplant outcomes.

RESULTS

Among the 859 patients, 153 (17.8%) underwent pre-emptive and 706 (82.2%), non-pre-emptive kidney transplantations. The rate of living donors was higher in the pre-emptive group (97.4% vs 73%, respectively). The 1-year graft survivals were 99.3% and 95.8% in pre-emptive and non-pre-emptive transplantation groups, respectively (P > .05). There was no significant difference between groups with respect to patient survival at 1 year (P > .05).

CONCLUSION

In conclusion, graft and patient survival rates between pre-emptive and non-pre-emptive kidney transplantation cases were comparable at 1 year. Pre-emptive kidney transplantation, which eliminates hemodialysis costs and complications, should be preferred as the optimal renal replacement therapy for end-stage renal disease patients.

Pre-emptive kidney transplantation to improve survival in patients with type 1 diabetes and imminent risk of ESRD

Despite significant improvements in the treatment of diabetic nephropathy over the past 20 years, patients with type 1 diabetes are at high risk of developing end-stage renal disease and high mortality once end-stage renal disease develops. Type 1 diabetic patients treated with predialysis (pre-emptive) transplantation have a lower death rate than type 1 diabetic patients treated with dialysis. Living donor kidney transplantation is possible before starting dialysis and is associated with better kidney and patient outcomes as compared with transplantation while on dialysis. In addition, a variety of potential donors can be used, not just young, well-matched family members. Through paired kidney donation, blood group ABO-incompatible transplants and transplants across the barrier of anti-human leukocyte antigen antibodies, diabetic patients can receive living donor kidney transplants even if their intended donor is not a good match for them. Despite these expanded options making living donation possible, only a minority of type 1 diabetic patients receive a pre-emptive kidney transplant. Multiple barriers remain that prevent type 1 diabetic patients from enjoying the reduced risk of death afforded by a pre-emptive kidney transplant, including lack of knowledge by primary care physicians, endocrinologists, and nephrologists; late referral for transplantation; patient and family misconceptions about timing of transplantation; and who can be a donor. The vast majority of type 1 diabetic patients are listed for kidney transplantation after the initiation of dialysis. Of these patients, thousands subsequently receive a live donor kidney transplant. We believe that the appropriate agencies and societies should address the barriers to pre-emptive kidney transplantation through nationwide educational initiatives and study the causes of failure to be transplanted before dialysis initiation.

Renal complications following lung and heart-lung transplantation

As survival improves after lung and heart-lung transplants, the long term detrimental impact of current management on renal function becomes more apparent as the number of non-renal solid organ transplant recipients on renal transplant waiting lists increases. Progressive chronic kidney disease (CKD) is a significant cause of morbidity and mortality in the transplant population. In this review we discuss the specific problems prior to lung or heart-lung transplant that predispose to CKD, as well as potential renal complications encountered during the peri- and post-transplant period. Significant acute and chronic nephrotoxicity is caused by calcineurin inhibitors (CNI). Mechanisms to decrease CNI exposure exist but have yet to be adopted in routine clinical care. Modifiable risk factors and the current screening and management approach taken at our institution are described. Pediatric nephrologists should be involved from an early stage. Future work will need to focus on identifying more accurate measures of renal function, given the limitations of current glomerular filtration rate estimation equations in a population where nutritional status may rapidly change post transplant. Multicentre studies of CNI minimisation strategies are required to guide future therapy that aims to minimise CKD development and progression in this vulnerable population.

Effectiveness of educational and social worker interventions to activate patients' discussion and pursuit of preemptive living donor kidney transplantation: a randomized controlled trial

BACKGROUND

Many patients with chronic kidney disease (CKD) have difficulty becoming actively engaged in the pursuit of preemptive living donor kidney transplantation.

STUDY DESIGN

The Talking About Live Kidney Donation (TALK) Study was a randomized controlled trial of the effectiveness of educational and social worker interventions designed to encourage early discussions and active pursuit of preemptive living donor kidney transplantation in patients with progressive CKD.

SETTING & PARTICIPANTS

We recruited participants with progressive CKD from academically affiliated nephrology practices in Baltimore, MD.

INTERVENTION

Participants randomly received: (1) usual care (routine care with their nephrologists), the (2) TALK education intervention (video and booklet), or the (3) TALK social worker intervention (video and booklet plus patient and family social worker visits).

OUTCOMES

We followed participants for 6 months to assess their self-reported achievement of behaviors reflecting their discussions about and/or pursuit of living donor kidney transplantation (discussions with family, discussions with physicians, initiating recipient evaluation, completing recipient evaluation, and identifying a potential living donor).

MEASUREMENTS

We assessed outcomes through a questionnaire at 1-, 3-, and 6-months follow-up.

RESULTS

Participants receiving usual care with their nephrologists (n = 44), TALK education (n = 43), and the TALK social worker (n = 43) were similar at baseline. TALK Study interventions improved participants' living donor kidney transplantation discussion and pursuit behaviors, with the social worker leading to greater patient activation (participants' predicted probability of achieving living donor kidney transplantation discussions, evaluations, or donor identification over 6 months): probabilities were 30% (95% CI, 20%-46%), 42% (95% CI, 33%-54%), and 58% (95% CI, 41%-83%), respectively, in the usual care, TALK education, and TALK social worker groups (P = 0.03).

LIMITATIONS

Our population was well educated and mostly insured, potentially limiting generalizability of our findings.

CONCLUSIONS

TALK interventions improved discussion and active pursuit of living donor kidney transplantation in patients with progressive CKD and may improve their use of preemptive living donor kidney transplantation.

Influence of maintenance steroids on the outcomes in deceased-donor kidney transplant recipients exposed to prolonged pretransplantation dialysis

BACKGROUND

Pre-transplant dialysis duration exerts a graded negative influence on outcomes after kidney transplantation. Higher immune reactivity associated with prolonged dialysis with consequent increased acute rejection could be contributory.

METHODS

Using the Organ Procurement and Transplant Network/United Network of Organ Sharing database, we identified patients ≥ 18 years of age who received deceased-donor kidney (DDK) transplants from 2000 to 2008 after being on maintenance dialysis for ≥ 4 years. Patients received induction therapy with rabbit antithymocyte globulin (r-ATG), alemtuzumab, or an interleukin-2 receptor blocker (IL-2B) and were discharged on calcineurin inhibitor (CNI)/mycophenolate mofetil (MMF)-based immunosuppression with or without steroid. Unadjusted and adjusted graft/patient survivals were compared in steroid versus no-steroid groups by induction type.

RESULTS

A total of 14,459 patients were identified, of which 7,684 received r-ATG (steroid, 6,098; no-steroid, 1,586), 1,292 alemtuzumab (steroid, 362; no-steroid, 930), and 5,483 an IL-2B agent (steroid, 5,107; no-steroid, 376). Adjusted graft survivals were similar for steroid versus no-steroid groups in r-ATG (hazard ratio [HR] 1.10, 95% confidence interval (CI) 0.96-1.26, P = .16), alemtuzumab (HR 0.88, 95% CI 0.65-1.19; P = .40), and IL-2B (HR 0.91, 95% CI 0.73-1.13; P = .38) groups. Adjusted patient survival for steroid versus no-steroid groups was inferior in r-ATG (HR 1.41, 95% CI 1.17-1.71; P < .001) but similar in alemtuzumab (HR 1.05, 95% CI 0.70-1.59; P = .80) and IL-2B (HR 1.17, 95% CI 0.86-1.58; P = .32) groups.

CONCLUSIONS

Our analysis failed to show a graft survival benefit for the addition of steroid to a CNI/MMF-based immunosuppression after induction with r-ATG, alemtuzumab, or an IL-2B agent in DDK recipients exposed to prolonged pretransplantation dialysis.

Preemptive deceased donor kidney transplantation: considerations of equity and utility

BACKGROUND AND OBJECTIVES

There exists gross disparity in national deceased donor kidney transplant availability and practice: waiting times exceed 6 years in some regions, but some patients receive kidneys before they require dialysis. This study aimed to quantify and characterize preemptive deceased donor kidney transplant recipients and compare their outcomes with patients transplanted shortly after dialysis initiation.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Using the Scientific Registry of Transplant Recipients database, first-time adult deceased donor kidney transplant recipients between 1995 and 2011 were classified as preemptive, early (on dialysis ≤1 year), or late recipients. Random effects logistic regression and multivariate Cox proportional hazards regression were used to identify characteristics of preemptive deceased donor kidney transplant and evaluate survival in preemptive and early recipients, respectively.

RESULTS

Preemptive recipients were 9.0% of the total recipient population. Patients with private insurance (adjusted odds ratio=3.15, 95% confidence interval=3.01-3.29, P<0.001), previous (nonkidney) transplant (adjusted odds ratio=1.94, 95% confidence interval=1.67-2.26, P<0.001), and zero-antigen mismatch (adjusted odds ratio=1.45, 95% confidence interval=1.37-1.54, P<0.001; Caucasians only) were more likely to receive preemptive deceased donor kidney transplant, even after accounting for center-level clustering. African Americans were less likely to receive preemptive deceased donor kidney transplant (adjusted odds ratio=0.44, 95% confidence interval=0.41-0.47, P<0.001). Overall, patients transplanted preemptively had similar survival compared with patients transplanted within 1 year after initiating dialysis (adjusted hazard ratio=1.06, 95% confidence interval=0.99-1.12, P=0.07).

CONCLUSIONS

Preemptive deceased donor kidney transplant occurs most often among Caucasians with private insurance, and survival is fairly similar to survival of recipients on dialysis for <1 year.

Performance measures for the evaluation of patients referred to the Toronto General Hospital's kidney transplant program

Given the increasing number of patients with end-stage renal disease in Ontario, there is a need to improve the efficiency and effectiveness of the pretransplant evaluation, to allow for a seamless progression through the various steps in the process. Toronto General Hospital's kidney transplant program is evaluating various performance measures, specifically looking at waiting times from referral to initial evaluation and initial evaluation to final disposition, to use as metrics for monitoring program performance and stimulate quality improvement.

Feasibility and acceptability of the TALK social worker intervention to improve live kidney transplantation

Live kidney transplantation (LKT) is underused by patients with end-stage renal disease. Easily implementable and effective interventions to improve patients' early consideration of LKT are needed. The Talking About Live Kidney Donation (TALK) social worker intervention (SWI) improved consideration and pursuit of LKT among patients with progressive chronic kidney disease in a recent randomized controlled trial: Patients and their families were invited to meet twice with a social worker to discuss their self-identified barriers to seeking LKT and to identify solutions to barriers. The authors audio recorded and transcribed all social worker visits to assess implementation of the TALK SWI and its acceptability to patients and families. The study social worker adhered to the TALK SWI protocol more than 90 percent of the time. Patients and families discussed medical (for example, long-term risks of transplant), psychological (for example, patients' denial of the severity of their disease), and economic (for example, impact of donation on family finances) concerns regarding LKT. Most patients and families felt that the intervention was helpful. Consistently high adherence to the TALK SWI protocol and acceptability of the intervention among patients and families suggest that the TALK SWI can be feasibly implemented in clinical practice.

Clinical research and social status investigation for donor and recipient of living-related kidney transplant

OBJECTIVE

Renal transplantation is the best options for treating end-stage renal disease. Better patient and allograft survival rates are provided by living donation, which has been safe, with minimal immediate and long-term risk for the donor. This study aims to investigate the life status and summarize the clinical experience in living-related kidney transplant (LRKT) before and after renal transplantation.

METHODS

A total of 310 cases of LRKT have been performed in our center since 1998. Tissue matching and risk factors assessment in donors and recipients were performed before donation. Small lumbar incision was used in all cases for unilateral nephrectomy. Donors and recipients were followed up regularly after renal transplantation.

RESULTS

All living donors were healthy, with normal renal function after unilateral nephrectomy. The 1- and 5-year patient/graft survival rates of LRKT were 98.3 %/97.6 % and 91.3 %/86.9 %, respectively. The cumulative incidence of delayed graft function (DGF) and acute rejection (AR) was 2.9 % (9 cases). Thirteen cases developed pulmonary infection (4.2 %) and eight cases were cured. The graft function in most cases returned to normal range soon after kidney transplant. Moreover, the creatinine and BUN levels of grafts donated by children or siblings of recipients were markedly lower than those donated by parents, at 1 month after transplant.

CONCLUSION

Adequate pretransplant assessment, better tissue matching, and reduced ischemia time may result in lower incidence of DGF, AR and higher patient/graft survival rates for LRKT. It is important to improve selection criteria and health assessment of donors. Long-term follow-up is essential to ensure a healthy life for donors and recipients after kidney transplant.

The timing of dialysis and kidney transplantation in type 1 diabetes

Despite significant improvements in the treatment of diabetic nephropathy over the last 20 years, patients with type 1 diabetes are at high risk of developing end-stage renal disease (ESRD) and high mortality once ESRD develops. The timing of dialysis initiation has occurred earlier over the years, but a recent study has led to a re-evaluation of that approach. People with type 1 diabetes treated with pre-dialysis (pre-emptive) transplantation have a lower death rate than people with type 1 diabetes treated with dialysis. Living donor kidney transplantation is possible before starting dialysis and is associated with better kidney and patient outcomes as compared to transplantation while on dialysis. Multiple barriers remain that prevent people with type 1 diabetes from enjoying the reduced risk of death afforded by a pre-emptive kidney transplant, including lack of knowledge by primary care physicians, endocrinologists and nephrologists, late referral for transplantation, patient and family misconceptions about timing of transplantation and who can be a donor. New data on both the optimal time to initiate dialysis or to pursue transplantation will be reviewed.

Preemptive kidney transplantation: has it come of age?

The benefits of preemptive kidney transplantation are manifold. By avoiding complications associated with dialysis, preemptive kidney transplantation offers significant benefits in terms of patient welfare and societal cost-saving. Patients transplanted preemptively also tend to enjoy better patient and graft survival, especially when done with a living-donor organ. While dialysis exposure limited to 6 to 12 months may not significantly impact post-transplant outcomes, longer period of dialysis has been shown to increase the risk of mortality, delayed graft function, acute rejection, and death-censored graft loss. The benefits of preemptive transplantation also extend to different age groups and end-stage kidney disease (ESKD) diagnoses. However, multiple barriers have prevented wider adoption of preemptive transplantation as the primary treatment of ESKD around the world. Timely preparation for ESKD and identification of living donors should be encouraged in all patients with advanced chronic kidney disease to increase the chance of preemptive transplantation.

Living kidney donor relationship in Caucasian and African American populations and implications for targeted donor education programs

PURPOSE

The opportunities for living kidney donation vary greatly among socioeconomic and racial groups. We reviewed our series of living donors to evaluate donor relationships in various groups.

MATERIALS AND METHODS

Donor and recipient records for 1000 patients were reviewed. An additional 857 records of potential recipients presenting with a donor were analyzed. We compared the relationship of the recipient to initial donor and individual who underwent nephrectomy.

RESULTS

There were 693 CC and 263 AA live kidney donors. In the AA population donors were first-degree 71%, second-degree 10%, and unrelated 19%. In the CC population donors were first-degree 57%, second-degree 6%, and unrelated 37% (p < 0.0001 for unrelated CC vs. AA). Spousal donation is more common in CC donors (13%) than AA donors (6%), p = 0.001. Donation from child to parent is more common in AA (33%) than CC donors (15%), p < 0.0001. AA recipients predominantly identified a child as a donor in 63% and 48% were cleared for donation. In contrast, 69% of CC recipients identified a spouse as a donor yet only 23% became donors, p < 0.001 and p < 0.001.

CONCLUSIONS

There is a higher incidence of unrelated donors in the caucasian population, vs. first degree relatives often being living donors in the AA population.

The kidney-first initiative: what is the current status of preemptive transplantation?

Preemptive kidney transplant (PKT)-defined as transplant before dialysis-has numerous advantages as a treatment approach for patients with advanced renal disease. In the past 15 years, PKT has become more common and has been performed at higher levels of estimated glomerular filtration rate, particularly among recipients of live-donor transplants, among whom timing of transplantation is easier to control. However, recent studies have raised important new concerns about unintended consequences of early versus late PKT. In this article, we review the convincing evidence that PKT offers diverse advantages for patients, discuss potential problems that might emerge from PKT at higher levels of renal function, examine the feasibility of a "just-in-time" PKT strategy for transplant centers, and discuss whether a new kidney allocation system could affect rates of PKT.

Shipping donor kidneys within Eurotransplant: outcomes after renal transplantation in a single-centre cohort study

BACKGROUND

Shipment of organs during the allocation process aims to improve human leucocyte antigen (HLA) matching but can also have a detrimental effect by prolonging cold ischaemia. The overall effect of organ exchange on post-transplant outcomes in the Eurotransplant (ET) region has not been investigated.

METHODS

This is a retrospective single-centre cohort study to investigate the effect of shipment of renal allografts on cold ischaemia times and the incidence of acute rejection (AR) and graft survival in 661 transplantations of deceased donor kidneys.

RESULTS

Forty-six per cent (N = 301) of the patients received a locally procured and 54% (N = 360) a shipped donor kidney. Locally procured donors tended to be older, more often hypertensive and had less frequently died from trauma. Recipients of shipped kidneys were at higher immunological risk, being younger, more frequently retransplanted and immunized against HLA antigens. Shipped kidneys had a 2.2-h prolongation of cold ischaemia time (18.0 versus 20.2 h; P < 0.0001) but significantly less HLA A, B and DR mismatches (2.20 versus 2.84; P < 0.0001). Recipients of shipped kidneys had an increased incidence of first-year AR [19 versus 13%; odds ratio 1.62 (1.06-2.49); P = 0.026] and death-censored graft loss [hazard ratio 1.6 (1.1-2.4); P = 0.01] that was no longer statistically significant after adjustments for risk factors by multivariable modelling.

CONCLUSIONS

Shipment of kidneys in the ET region is associated with a modest increase in cold ischaemia time and significantly better HLA matching. This allows for successful transplantation of higher risk patients with no significant penalty with regard to AR rates or death-censored graft survival.

Preemptive kidney transplantation in systemic lupus erythematosus

Preemptive kidney transplantation is associated with superior outcomes. Patients who have kidney failure due to systemic lupus erythematosus (SLE) may not receive a preemptive kidney transplant because of the concern for risk of disease recurrence with shortened graft and patient survival. We identified 8001 patients in the United Network for Organ Sharing dataset who underwent kidney transplantation between October 1987 and February 2009 with kidney failure due to SLE. Seven hundred thirty patients received a preemptive kidney transplant with 7271 patients who were on dialysis before transplantation; their mean ages were 40.0±11.6 years and 36.9±11.7 years, respectively, (P<.01). Women constituted 82.5% of preemptive and 81.4% of non-preemptive groups (P=.47). Preemptive transplant recipients were more likely to receive a living donor kidney transplant (odds ratio [OR]=3.6; 95% confidence interval [CI]=3.3-4.5; P<.01). In unadjusted analyses, preemptive transplantation was associated with lower risk of recipient death (hazard ratio [HR]=0.52; 95% CI=0.38-0.70; P<.01). The difference remained significant after adjustment fr covariates (HR=0.55; 95% CI=0.36-0.84; P<.01). Graft survival was also superior among preemptive kidney transplant recipients in both unadjusted (HR=0.56; 95% CI=0.49-0.68; P<.01), and adjustment analyses (HR=0.69; 95% CI=0.55-0.86; P<.01). We concluded that preemptive kidney transplantation among patients with SLE was associated with superior patient and graft outcomes and should be considered when feasible.

Preemptive deceased-donor renal transplant in adults: single-center experience and outcome

OBJECTIVES

Preemptive renal transplant has been associated with better survival of both the allograft and the recipient than has conventional renal transplant. It remains unclear, however, whether preemptive transplant is optimal for renal replacement therapy. We describe our experience with preemptive renal transplant.

MATERIALS AND METHODS

We retrospectively analyzed 32 preemptive and 132 nonpreemptive deceased-donor renal transplants performed in our center between January 2006 and January 2008.

RESULTS

The mean follow-up was 47.44 ± 11.92 months in the preemptive group, compared with 47.49 ± 14.87 months in the nonpreemptive group. The 1-, 3-, and 5-year patient survival rates were 93.8%, 90.6%, and 90.6% in the preemptive group, and 92.4%, 90.9%, and 87.6% in the nonpreemptive group; and the 1-, 3-, and 5-year graft survival rates were 93.8%, 93.8%, and 93.8% in the preemptive, and 89.4%, 85.6%, and 73.8% in the nonpreemptive group. None of these differences was statistically significant. Rates of acute rejection (P = .04) and delayed graft function (P = .03) were significantly lower in the preemptive group. The mean plasma creatinine levels at 1 day before transplant and at 1 and 12 months after transplant were 715.16 ± 114.92 μmol/L, 113.15 ± 29.17 μmol/L, and 94.59 ± 18.56 μmol/L in the preemptive group, and 772.62 ± 111.38 μmol/L, 118.46 ± 30.94 μmol/L, and 100.78 ± 15.03 μmol/L in the nonpreemptive group. None of these differences was statistically significant.

CONCLUSIONS

Preemptive transplant can yield outcomes comparable to those of renal transplant after dialysis, and result in better quality of life for patients with end-stage renal disease, as well as reduced cost. Preemptive transplant is a better choice for renal replacement therapy, if possible.

Impact of surgeon experience on complication rates and functional outcomes of 484 deceased donor renal transplants: a single-centre retrospective study

OBJECTIVE

To determine how postoperative and functional outcomes after deceased donor renal transplantation (DDRT) are related to surgeon experience.

PATIENTS AND METHODS

The outcomes of 484 adult DDRT performed by 13 urological surgeons were retrospectively reviewed. After completion of a staged renal transplant training programme under supervision of an attending urological transplant surgeon, the 13 surgeons were either assigned to the inexperienced group (n = 8) or the experienced group (n = 5). Surgeons in the experienced group had performed more than 30 unsupervised DDRT in a standard fashion with routine ureteric stenting. Between 1988 and 2005, inexperienced surgeons performed 152 DDRT, whereas experienced surgeons performed 332 DDRT.

RESULTS

Patient and graft survival at 2 hyears were 98% and 94.7%, respectively. Early graft loss in five recipients was unrelated to surgeon experience. Delayed graft function occurred in 29% of cases and median 1-year serum-creatinine was 1.48 mg/dL, with no difference between surgeon groups. Postoperative bleeding and lymphocele formation were the most frequent surgical complications, with an equal distribution between groups. Ureteric complications had a significantly higher incidence among inexperienced surgeons (6.6% versus 2.7%; P = 0.04).

CONCLUSION

We conclude that DDRT as performed by inexperienced urological renal transplant surgeons has both acceptable short- and long-term outcomes.

Age and the associations of living donor and expanded criteria donor kidneys with kidney transplant outcomes

BACKGROUND

Recent studies show a survival advantage with kidney transplant in elderly patients compared with those on dialysis therapy.

STUDY DESIGN

In our present study, we examined and compared the association of expanded criteria donor (ECD) kidney and living kidney donation with the outcome of kidney transplant across different ages, including elderly recipients.

SETTING & PARTICIPANTS

Using the Scientific Registry of Transplant Recipients, we identified 145,470 adult kidney transplant patients. Mortality and death-censored transplant failure risks were estimated by Cox proportional regression analyses during follow-up with a median of 3.9 years.

PREDICTORS

ECD kidney and living kidney donation and age compared with others.

OUTCOMES

Mortality and death-censored transplant failure risk.

RESULTS

Patients were aged 45 ± 16 years and included 40% women and 19% patients with diabetes. Compared with transplant recipients 55 to younger than 65 years, the fully adjusted death-censored transplant failure risk was higher in patients 75 years and older (HR, 1.30; 95% CI, 1.09-1.56), 35 to younger than 55 years (HR, 1.13; 95% CI, 1.08-1.17), and 18 to younger than 35 years (HR, 1.64; 95% CI, 1.57-1.71). Compared with non-ECD kidneys, ECD kidneys were significant predictors of mortality in nonelderly patients (18-<35 years: HR, 1.46 [95% CI, 1.19-1.77]; 35-<55 years: HR, 1.23 [95% CI, 1.14-1.32]; and 55-<65 years: HR, 1.26 [95% CI, 1.15-1.38]) and patients 65 to younger than 70 years (HR, 1.20; 95% CI, 1.05-1.36), but not in other groups of elderly patients (HRs of 1.12 [95% CI, 0.93-1.36] for 70-<75 years and 1.04 [95% CI, 0.74-1.47] for ≥75 years). Similar results were found for risk of transplant loss. Compared with deceased donor kidneys, a living donor kidney was associated with better survival in all age groups and lower transplant loss risk in patients younger than 70 years.

LIMITATIONS

Unmeasured confounders cannot be adjusted for.

CONCLUSIONS

For deceased donors, ECD kidneys are not associated with increased mortality or transplant failure in recipients older than 70 years. For all types of donors, the persistent association between living donor kidneys and lower all-cause mortality across all ages suggests that, if possible, elderly patients gain longevity from living donor kidney transplant.

Long-term outcomes of kidney donors

PURPOSE OF REVIEW

Living kidney donors face a unique decision of self-sacrifice that is not without potential risk. The purpose of this review is to highlight existing research regarding the perioperative morbidity, mortality and long-term outcomes of living kidney donors.

RECENT FINDINGS

Recent studies of long-term donor survival have affirmed that the life expectancy for living kidney donors is excellent and their risk of end-stage renal disease (ESRD) is not increased. Long-term health outcomes for living donors representing minority groups, however, may not be as favorable. Recent studies conclude that African-American and Hispanic donors, similarly to nondonors of the same race, are at higher risk of developing chronic kidney disease (CKD), hypertension, and diabetes mellitus. Outcomes in medically complex donors have also generated considerable attention, and the evidence on outcomes among otherwise healthy obese and older donors appears to be reassuring.

SUMMARY

Living kidney donation is a superior transplantation option for many individuals with ESRD. The survival and health consequences of living donation have proven to be excellent. These favorable outcomes stem from careful screening measures, and further research endeavors are needed to ensure long-term living donor safety in high-risk donors.

Disparities in provision of transplant information affect access to kidney transplantation

Recently Centers for Medicare and Medicaid Services (CMS) began asking providers on Form-2728 whether they informed patients about transplantation, and if not, to select a reason. The goals of this study were to describe national transplant education practices and analyze associations between practices and access to transplantation (ATT), based on United States Renal Data System (USRDS) data from 2005 to 2007. Multinomial logistic regression was used to examine factors associated with not being informed about transplantation, and modified Poisson regression to examine associations between not being informed and ATT (all models adjusted for demographics/comorbidities). Of 236,079 incident end-stage renal disease (ESRD) patients, 30.1% were not informed at time of 2728 filing, for reasons reported by providers as follows: 42.1% unassessed, 30.4% medically unfit, 16.9% unsuitable due to age, 3.1% psychologically unfit and 1.5% declined counsel. Older, obese, uninsured, Medicaid-insured and patients at for-profit centers were more likely to be unassessed. Women were more likely to be reported as unsuitable due to age, medically unfit and declined, and African Americans as psychologically unfit. Uninformed patients had a 53% lower rate of ATT, a disparity persisting in the subgroup of uninformed patients who were unassessed. Disparities in ATT may be partially explained by disparities in provision of transplant information; dialysis centers should ensure this critical intervention is offered equitably.

Practice patterns in evaluation of living kidney donors in United Network for Organ Sharing-approved kidney transplant centers

INTRODUCTION

The current pattern of evaluation for living kidney donors was investigated.

METHODS

We designed a 37-question electronic survey to collect information about living kidney donor evaluation. Of the 181 United Network for Organ Sharing (UNOS)-approved centers, 72 responded. Survey responses were coded and downloaded into SPSS. Data was expressed as means and standard deviations or the percentage of centers with specific responses.

RESULTS

66% of the centers used a cut-off of <80 ml/min for exclusion of living kidney donors. 24-hour urine measuring creatinine clearance (CrCl) was the most common screening method for glomerular filtration rate (GFR) assessment in potential living donors. 56% of the centers excluded donors with blood pressure (BP) >140/90, whereas 22.7 and 7.1% excluded patients with pre-hypertension with a cut-off BP of 130/85 and 120/80, respectively. 66% of the centers used 24-hour urine creatinine to assess for proteinuria. 20% of the centers accepted living kidney donors with microalbuminuria and 84% accepted patients with a history of nephrolithiasis. 24% of the centers reported use of formal cognitive testing of potential living donors.

DISCUSSION

There were significant variations in exclusion criteria based on GFR, history of kidney stones, body mass index, BP and donors with urinary abnormalities. The definitions for hematuria and proteinuria were variable. There is a need for uniformity in selection and for a living donor registry. We also recommend raising the cut-off for estimated GFR to 90 ml/min to account for 10-15% overestimation when CrCl is used.

Outcomes of preemptive kidney with or without subsequent pancreas transplant compared with preemptive simultaneous pancreas/kidney transplantation

BACKGROUND

Prior studies have indicated that type 1 diabetic (T1DM) recipients of a simultaneous pancreas-kidney (SPK) transplant have greater short-term mortality compared with living donor kidney (LDK) transplantation. Whether this association remains and how outcomes compare to deceased donor kidney (DDK) transplantation in the preemptive setting are unknown.

METHODS

Using data on recipients transplanted between 2000 and 2010 from the Organ Procurement and Transplantation Network/United Network of Organ Sharing, patient and graft survival (calculated from the time of kidney transplant) of pancreas after preemptive LDK (PALK, n=389), preemptive LDK not receiving a pancreas transplant (LDK/noP, n=289), preemptive DDK (n=112), and preemptive SPK transplantations (n=1402) were compared.

RESULTS

At 6 years, patient survival was excellent (PALK=89.4%, LDK/noP=84.9%, DDK=81.2%, and SPK=91.1%) and not different between PALK, LDK/noP, and SPK (P value vs. PALK: LDK/noP=0.08; SPK=0.85) but was lower with preemptive DDK versus preemptive PALK (P=0.03). When both LDK groups were considered together, there was higher mortality in the first 180 days after transplant with preemptive DDK (3.7% vs. 1.1%; P=0.03) and similar mortality with preemptive SPK (2.3%; P=0.07). After multivariate adjustment, there was a trend toward increased risk of death with preemptive DDK compared with preemptive PALK (hazard ratio: 1.91; 95% confidence interval: 0.95-3.84).

CONCLUSIONS

Patient survival associated with preemptive transplantation among T1DM recipients was excellent at 6 years, with the greatest survival favoring PALK, LDK/noP, and SPK rather than DDK. In contrast with prior studies reporting greater short-term mortality with SPK among the general T1DM population, short-term mortality after preemptive transplant is similar between LDK and SPK.

Preemptive kidney transplantation: experience in two centers

INTRODUCTION

End-stage renal disease (ESRD) is a prevalent, important cause of death. Transplantation increases survival and improves the quality of life of patients with ESRD while long-term dialysis is related to poor outcomes even among patients who undergo subsequent transplantations.

OBJECTIVES

To compare the advantages of preemptive procedures with kidney transplants among patients on renal replacement therapy.

METHODS

This retrospective study was performed in two Córdoba city transplantation centers. Patients were divided into three groups: preemptive kidney transplant (PKT), patients on hemodialysis who received living donor kidney transplants (LDT), and subjects who received grafts from deceased donors (DDT). Serum creatinine, delayed graft function (DGF), subclinical rejection, and interstitial fibrosis/tubular atrophy (IF/TA) were evaluated at 6 months.

RESULTS

Eighty patients were included: PKT (n = 28), LDT (n = 27), DDT (n = 25) mean age 29, 30, and 35 years, respectively. Women predominated among PKT and men in the other groups. In all groups, cyclosporine was the calcineurin inhibitor mostly used. Creatinine at 6 months was lower in the living donor groups (1.26 mg/dL PKT and 1.32 mg/dL LDT; P = NS) in relation to the deceased donor group (1.96 mg/dL; P < .05). DDT had the highest rate of DGF: 44% DDT versus 11.5% LDT vs 0% PKT (P < .05). Subclinical rejection was significantly lower among preemptive transplantations: PKT 7.6% versus LDT 18.5% versus DDT 24% (P < .05). IF/TA was higher in transplants from deceased donors: PKT 11.1%; LDT 11.5%; DDT 32%.

CONCLUSIONS

Preemptive kidney transplantation offered the advantages of a lower creatinine, no DGF, as well as a reduced incidence of subclinical rejection and chronic allograft nephropathy at 6 months posttransplantation.

Kidney transplantation outcomes in African-, Hispanic- and Caucasian-Americans with lupus

African-American recipients of kidney transplants with lupus have high allograft failure risk. We studied their risk adjusting for: (1) socio-demographic factors: donor age, gender and race-ethnicity; recipient age, gender, education and insurance; donor–recipient race-ethnicity match; (2) immunologic factors: donor type, panel reactive antibodies, HLA mismatch, ABO blood type compatibility, pre-transplant dialysis, cytomegalovirus risk and delayed graft function (DGF); (3) rejection and recurrent lupus nephritis (RLN). Two thousand four hundred and six African-, 1132 Hispanic-, and 2878 Caucasian-Americans were followed for 12 years after transplantation. African- versus Hispanic- and Caucasian-Americans received more kidneys from deceased donors (71.6%, 57.3% and 55.1%) with higher two HLA loci mismatches for HLA-A (50%, 39.6% and 32.4%), HLA-B (52%, 42.8% and 35.6%) and HLA-DR (30%, 24.5% and 21.1%). They developed more DGF (19.5%, 13.6% and 13.4%). More African- versus Hispanic- and Caucasian-Americans developed rejection (41.7%, 27.6% and 35.9%) and RLN (3.2, 1.8 and 1.8%). 852 African-, 265 Hispanic-, and 747 Caucasian-Americans had allograft failure ( p < 0.0001). After adjusting for transplant era, socio-demographic-immunologic differences, rejection and RLN, the increased hazard ratio for allograft failure of African- compared with Caucasian-Americans became non-significant (1.26 [95% confidence interval 0.78–2.04]). African-Americans with lupus have high prevalence of risk factors for allograft failure that can explain poor outcomes.

Trends in the timing of pre-emptive kidney transplantation

Pre-emptive kidney transplantation is considered the best available renal replacement therapy, but no guidelines exist to direct its timing during CKD progression. We used a national cohort of 19,471 first-time pre-emptive kidney transplant recipients between 1995-2009 to evaluate patterns and implications of transplant timing. Mean estimated GFR (eGFR) at the time of pre-emptive transplant increased significantly over time, from 9.2 ml/min/1.73 m(2) in 1995 to 13.8 ml/min/1.73 m(2) in 2009 (P<0.001). Patients with eGFR ≥ 15 ml/min/1.73 m(2) represented an increasing proportion of pre-emptive transplant recipients, from 9% in 1995 to 35% in 2009; the trend for patients with eGFR ≥ 10 was similar (30% to 72%). We did not detect statistically significant differences in patient survival or death-censored graft survival between strata of eGFR at the time of transplant, either in the full cohort or in subgroup analyses of patients who might theoretically benefit from earlier pre-emptive transplantation. In summary, pre-emptive kidney transplantation is occurring at increasing levels of native kidney function. Earlier transplantation does not appear to associate with patient or graft survival, suggesting that earlier pre-emptive transplantation may subject donors and recipients to premature operative risk and waste the native kidney function of recipients.

Identifying and addressing barriers to African American and non-African American families' discussions about preemptive living related kidney transplantation

CONTEXT

Ethnic/racial minority and nonminority families' perceived barriers to discussing preemptive living related kidney transplantation (LRKT) and their views on the potential value of health care professionals trained to address barriers are unknown. OBJECTIVE, SETTING, AND PARTICIPANTS: To collect pilot data for evaluating perceived barriers to preemptive LRKT and to inform the development of a culturally sensitive intervention to improve families' consideration of LRKT. In 4 structured group interviews of African American and non-African American patients (2 groups) with progressing chronic kidney disease and their family members (2 groups), participants' perceived barriers to initiating LRKT discussions and their views regarding the value of social workers to support discussions were explored.

RESULTS

Patients' barriers included concerns about their (1) ability to initiate discussions, (2) discussions being misinterpreted as donation requests, (3) potential burdening of family members, (4) uncertainty about when to initiate discussions, and (5) inducing guilt or coercing family members. Family members' barriers included (1) feeling overwhelmed by patients' illness, (2) patients' denial about their illness, (3) caregiver stress, and (4) uncertainty about their own health or the health of other family members who might donate or need a kidney in the future. Participants reported that social workers could facilitate difficult or awkward discussions and help families understand the LRKT process, address financial concerns, and cope emotionally. Themes were similar between African Americans and non-African Americans.

CONCLUSIONS

Families identified several barriers to discussing preemptive LRKT that could be addressed by social workers. Further research must be done to determine whether social workers need to tailor interventions to address families' cultural differences.

Long-term survival of living donor renal transplants: A single center study

Kidney transplantation is the treatment of choice for end-stage renal disease. The aim of this study was to determine the ten-year graft survival rate of renal transplantation in patients who have been transplanted from live donors. This is a historical cohort study designed to determine the organ survival rate after kidney transplantation from live donor during a 10-year period (from March 1999 to March 2009) on 843 patients receiving kidney transplant in the transplantation center of Namazi hospital in Shiraz, Iran. Kaplan-Meier method was used to determine the survival rate, log-rank test was used to compare survival curves, and Cox proportional hazard model was used to multivariate analysis. Mean follow-up was 53.07 ± 34.61 months. Allograft survival rates at 1, 3, 5, 7, and 10 years were 98.3, 96.4, 92.5, 90.8, and 89.2%, respectively. Using Cox proportional hazard model, the age and gender of the donors along with the creatinine level of the patients at discharge were shown to have a significant influence on survival. The 10-year graft survival rate of renal transplantation from living donor in this center is 89.2%, and graft survival rate in our cohort is satisfactory and comparable with reports from large centers in the world.

Protocol of a randomized controlled trial of culturally sensitive interventions to improve African Americans' and non-African Americans' early, shared, and informed consideration of live kidney transplantation: the Talking About Live Kidney Donation (TALK) Study

Background

Live kidney transplantation (LKT) is underutilized, particularly among ethnic/racial minorities. The effectiveness of culturally sensitive educational and behavioral interventions to encourage patients' early, shared (with family and health care providers) and informed consideration of LKT and ameliorate disparities in consideration of LKT is unknown.

Methods/Design

We report the protocol of the Talking About Live Kidney Donation (TALK) Study, a two-phase study utilizing qualitative and quantitative research methods to design and test culturally sensitive interventions to improve patients' shared and informed consideration of LKT. Study Phase 1 involved the evidence-based development of culturally sensitive written and audiovisual educational materials as well as a social worker intervention to encourage patients' engagement in shared and informed consideration of LKT. In Study Phase 2, we are currently conducting a randomized controlled trial in which participants with progressing chronic kidney disease receive: 1) usual care by their nephrologists, 2) usual care plus the educational materials, or 3) usual care plus the educational materials and the social worker intervention. The primary outcome of the randomized controlled trial will include patients' self-reported rates of consideration of LKT (including family discussions of LKT, patient-physician discussions of LKT, and identification of an LKT donor). We will also assess differences in rates of consideration of LKT among African Americans and non-African Americans.

Discussion

The TALK Study rigorously developed and is currently testing the effectiveness of culturally sensitive interventions to improve patients' and families' consideration of LKT. Results from TALK will provide needed evidence on ways to enhance consideration of this optimal treatment for patients with end stage renal disease.

Trial Registration

ClinicalTrials.gov number, NCT00932334

Association of pretransplant renal replacement therapy duration with outcome in kidney transplant recipients: a prevalent cohort study in Slovenia

The effect of renal replacement therapy (RRT) duration on kidney transplant outcome is controversial. The aim of this study was to analyze the association between pretransplant RRT duration versus patient and graft survival. The study cohort included 445 recipients of a deceased-donor kidney transplant between January 2000 and December 2009. Pretransplant RRT duration as a continuous variable and divided into time categories was the risk factor of interest. Patient and death-censored graft survival were the outcomes. Survival since the onset of RRT was calculated to avoid lead-time bias. Median pretransplant RRT duration was 4.7 years. The duration of RRT was longer in 33 patients who died (median 6.8 vs. 4.6 years; P = 0.022) and 56 patients who lost their graft (5.7 vs. 4.6 years; P = 0.035). Pretransplant RRT duration, as a continuous variable, was associated with a non-significant increase in the risk of recipient death (hazard ratio [HR] 1.01 per year of RRT; P = 0.09) and death-censored graft loss (HR 1.02; P = 0.12). When RRT was studied as a categorical variable, the mortality risk reached statistical significance when the patient had been on RRT for more than 4.7 years (HR 2.12; P = 0.042). Pretransplant RRT duration was not associated with an increased risk for recipient death if patient survival was calculated since the onset of RRT (HR 0.98 per year; P = 0.21). This study suggests that a longer RRT duration negatively impacts on post-transplant patient and graft survival; however, when pretransplant patient survival is accounted for, RRT duration has no significant effect on patient outcome.

Graft survival rate of renal transplantation: a single center experience, (1999-2009)

BACKGROUND

Renal transplantation is the best option for treatment of the end-stage renal diseases and has more advantages than dialysis. The objective of this study is to determine the ten-year graft survival rate of renal transplantation and its associated factors in patients who have been transplanted from March 1999 to March 2009 in Nemazee Hospital Transplantation Center.

METHODS

This is a historical cohort study of 1356 renal transplantation carried out during 1999 to 2009. Kaplan-Meier method was used to determine the survival rate, log rank test to compare survival curves, and Cox regression model to determine hazard ratios and for modeling of variables affecting survival.

RESULTS

The 1, 3, 5, 7 and 10 years graft survival rates were 96.6, 93.7, 88.9, 87.1 and 85.5 percent, respectively.Cox regression model revealed that the donor source and creatinine level at discharge were effective factors in graft survival rate in renal transplantation.

CONCLUSION

Our study showed that 10 year graft survival rate for renal transplantation in Nemazee Hospital Transplantation Center was 85.5% and graft survival rate was significantly related to recipients and donor's age,donor source and creatinine level at discharge. Our experience in renal transplantation survival rate indicates asuccess rate comparable to those noted in other reports.

Identifying and Addressing Barriers to African American and Non—African American Families' Discussions about Preemptive Living Related Kidney Transplantation

Context

Ethnic/racial minority and nonminority families' perceived barriers to discussing preemptive living related kidney transplantation (LRKT) and their views on the potential value of health care professionals trained to address barriers are unknown.

Objective, Setting, and Participants

To collect pilot data for evaluating perceived barriers to preemptive LRKT and to inform the development of a culturally sensitive intervention to improve families' consideration of LRKT. In 4 structured group interviews of African American and non—African American patients (2 groups) with progressing chronic kidney disease and their family members (2 groups), participants' perceived barriers to initiating LRKT discussions and their views regarding the value of social workers to support discussions were explored.

Results

Patients' barriers included concerns about their (1) ability to initiate discussions, (2) discussions being misinterpreted as donation requests, (3) potential burdening of family members, (4) uncertainty about when to initiate discussions, and (5) inducing guilt or coercing family members. Family members' barriers included (1) feeling overwhelmed by patients' illness, (2) patients' denial about their illness, (3) caregiver stress, and (4) uncertainty about their own health or the health of other family members who might donate or need a kidney in the future. Participants reported that social workers could facilitate difficult or awkward discussions and help families understand the LRKT process, address financial concerns, and cope emotionally. Themes were similar between African Americans and non—African Americans.

Conclusions

Families identified several barriers to discussing preemptive LRKT that could be addressed by social workers. Further research must be done to determine whether social workers need to tailor interventions to address families' cultural differences.

Live donor kidney transplantation: attitudes of patients and health care professionals concerning the pre-surgical pathway and post-surgical follow-up

OBJECTIVES

We surveyed the following groups of individuals concerning their attitudes towards the pathway leading up to live donor kidney transplantation (LDKT) and post-operative follow-up: kidney transplant (deceased and live donor) recipients, live kidney donors and medical and nursing staff caring for end-stage renal disease and dialysis patients.

MATERIALS AND METHODS

Participants were recruited within a tertiary renal and transplant centre and invited to complete anonymized questionnaires, be involved in focus groups and undertake structured interviews.

RESULTS

A total of 464 participants completed the questionnaire (36% health care professionals and 64% patients). Most perceived donor risk as small or very small (62%), and 49% stated that a potential donor should be given up to 3 months to reconsider the decision to donate. Participants were almost equally divided as to whether consensus of the donor's family is necessary (46%) or not (44%) in LDKT. Seventy-one percentage of the participants suggested that patients have a greater appreciation of a LDKT if they have been on dialysis; 58% of participants thought that donor and recipient should recuperate beside each other after surgery; 45% thought that the post-operative follow-up for the donor should last up to a year; and 83% thought that donor follow-up should include medical status and quality of life. In the interviews, participants expressed several interesting views.

CONCLUSIONS

Participants believed that LDKT is safe for the donor, and the pathway to surgery and post-operative follow-up should be performed in a way that ensures lack of coercion and includes family support and an extensive post-operative follow-up.

Dual-kidney transplants as an alternative for very marginal donors: long-term follow-up in 63 patients

BACKGROUND

Organ shortage has led to the use of dual-kidney transplant (DKT) of very marginal donors into a single recipient to increase the use of marginal organs. To date, few data are available about the long-term outcome of DKT and its usefulness to increase the pool of available organ.

METHODS

We conducted a single-center cohort study of DKTs with longitudinal follow-up over an 8-year period. Between 1999 and 2007, 63 DKTs were performed. All kidneys from donors younger than 75 years refused by all centers for single transplantation, and kidneys from donors aged 75 years or older were routinely evaluated based on preimplantation glomerulosclerosis. Renal function, patient or graft survival, and perioperative complications were compared with 66 single kidneys from expanded criteria donors (ECD) and 63 ideal kidney donors.

RESULTS

After a median follow-up of 56 months, patient or graft survival was similar between the three groups. Twelve-, 36-, and 84-month creatinine clearance were similar for DKT and ECD (12 months: 58 and 59 mL/min; 36 months: 54 and 60 mL/min; and 84 months: 62 and 51 mL/min, respectively). For the study period, the routine evaluation of very marginal kidneys for DKT in our center has led to an increase of 47% in the transplants from donors aged 50 years or older, which represent 12% at the level of our organ procurement organization.

CONCLUSIONS

DKT patients can expect long-term results comparable with single kidney ECD. The implementation of a DKT program in our unit safely increased the pool of organs from marginal donors.

Effect of pretransplant dialysis modality and duration on long-term outcomes of children receiving renal transplants

BACKGROUND

Adults receiving preemptive renal transplants have better allograft survival. Our study investigated differences in graft and patient survival based on need for, and duration of, pretransplant dialysis in pediatric renal transplant recipients.

METHODS

Data on pediatric kidney transplants from January 1995 to December 2000 from the Organ Procurement and Transplantation Network were included. Multivariable Cox proportional hazards analysis was performed to determine the effect of pretransplant dialysis on graft and patient survival.

RESULTS

Of 3606 transplants, 28% were preemptive, 38% followed pretransplant hemodialysis (HD), and 34% peritoneal dialysis (PD). The 1-year acute rejection rate was lowest for the preemptive group (36%) compared with the HD (45.5%; P=0.0002) and PD (44.2%; P=0.0008) groups. On multivariable analysis, an increased relative risk of graft failure was seen with, among other variables, deceased donor transplantation and acute rejection within the first year, but not with pretransplant dialysis. When analyzed separately by donor source, pretransplant dialysis had no effect on graft survival for deceased donor graft recipients, whereas for living donor recipients, the use and duration of pretransplant HD adversely affected pediatric renal graft survival in a linear manner. No such effect was seen with pretransplant PD.

CONCLUSIONS

There is a linear increase in the risk of graft failure with the use of and increasing duration of pretransplant HD for living donor grafts. This indicates another reason to minimize the need for and duration of pretransplant HD in children with chronic kidney disease.

Caring for Patients with CRF: Rewards and Benefits

Patients with CRF usually progress through different stages before they reach ESRD and require special medical, social and psychological care and support during the pre-ESRD and following renal replacement therapy (RRT). Early referral of patients with CRF has the advantage of receiving adequate management and regular followup, with significant reduction in cardiovascular morbidity and mortality, attending an education program, prepared psychologically, participate in the decision of type of RRT, preemptive kidney transplantation, early creation of dialysis access, and adequate training in selected modality of RRT. During the early stages of commencement of RRT, psychological support and social care with rehabilitation program are mandatory. The degree of involvement and interaction must be individualized according to the needs of patient and type of RRT. A multidisciplinary team is crucial for implementation of a variety of strategies to help staff intervene more effectively in meeting the care needs of CRF patients.

Clinical outcome of preemptive kidney transplantation in patients with diabetes mellitus

End-stage renal disease (ESRD) caused by diabetic nephropathy is increasing throughout the world. The survival of diabetic patients treated by transplantation has improved nowadays. Although recent studies have demonstrated preemptive kidney transplantation to be associated with better graft survival in CKD patients, the effect of pre-transplantation dialysis on graft outcomes among diabetic ESRD patients is unclear. This analysis summarized our experience with preemptive kidney transplantation in diabetic ESRD patients by retrospectively comparing 70 such patients transplanted between 1995 and 2009. These 70 patients were divided into two groups: 30 patients underwent preemptive and the other 40 transplantation after maintenance hemodialysis or peritoneal dialysis. We compared graft survivals, acute rejection episodes, postoperative complications, and delayed graft function rates. The 10-year patient survival of 100% in the preemptive group was similar to that of the nonpreemptive group (85%, P = .11). But the 10 year graft survival was higher among the preemptive than the nonpreemptive group (100% vs 75%, P = .02). Pre-transplantation modality did not affect graft survival. Therefore, preemptive kidney transplantation should be applied to eligible patients with diabetic ESRD.

Risk for ESRD in type 1 diabetes remains high despite renoprotection

Historically, patients with type 1 diabetes and macroalbuminuria had high competing risks: cardiovascular death or renal failure. Here, we assessed these risks in patients receiving therapies implemented during the last 30 years. Between 1991 and 2004, we enrolled 423 white patients with type 1 diabetes who developed macroalbuminuria (albumin excretion rate, ≥300 μg/min). With follow-up for 98% through 2008, ESRD developed in 172 patients (incidence rate, 5.8/100 person-years), and 29 died without ESRD (mortality rate, 1/100 person-years). The majority of these outcomes occurred between ages 36 and 52 years with durations of diabetes of 21 to 37 years. The 15-year cumulative risks were 52% for ESRD and 11% for pre-ESRD death. During the 15 years of follow-up, the use of renoprotective treatment increased from 56 to 82%, and BP and lipid levels improved significantly; however, the risks for both ESRD and pre-ESRD death did not change over the years analyzed. There were 70 post-ESRD deaths, and the mortality rate was very similar during the 1990s and the 2000s (11/100 person-years versus 12/100 person-years, respectively). Mortality was low in patients who received a pre-emptive kidney transplant (1/100 person-years), although these patients did not differ from dialyzed patients with regard to predialysis eGFR, sex, age at onset of ESRD, or duration of diabetes. In conclusion, despite the widespread adoption of renoprotective treatment, patients with type 1 diabetes and macroalbuminuria remain at high risk for ESRD, suggesting that more effective therapies are desperately needed.

Preemptive transplantation and the transplant first initiative

PURPOSE OF REVIEW

Preemptive kidney transplant (PKT) is the focus of a new initiative, 'Transplant First'. This initiative focuses on increasing patient transition to transplantation prior to the need for dialysis. This review will evaluate the benefits of PKT and means to accomplish this goal.

RECENT FINDINGS

Outcomes data show PKT significantly improves long-term survival for the recipient and the allograft. In addition quality of life is improved. This also holds true for children and particularly for adolescents. In 2008, 5.7% of incident patients with end-stage renal disease were placed on the waiting list before beginning dialysis and 0.8% underwent preemptive living donor transplant before wait listing. If patients are evaluated before starting dialysis and are acceptable candidates, up to 40% will receive a preemptive transplant. Recent articles stress that patients want information from their physician; important impediments to PKT remain provider and patient education, insurance coverage and patient reluctance to ask for living donation.

SUMMARY

Preemptive transplant saves lives. Increased education focused on providers, patients and entire communities is key, as is an increase in living donation. Furthermore, to maximize the impact of transplant first, increased living donor protections and immunosuppression coverage for the life of the allograft are essential.