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Narasaki Y, Siu MK, Nguyen M, Kalantar-Zadeh K, Rhee CM. Personalized nutritional management in the transition from non-dialysis dependent chronic kidney disease to dialysis. Kidney Res Clin Pract 2024; 43:575-585. [PMID: 38738275 DOI: 10.23876/j.krcp.23.142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 11/10/2023] [Indexed: 05/14/2024] Open
Abstract
Dialysis has been the dominant treatment regimen in end-stage kidney disease as a means to remove uremic waste products and to maintain electrolyte, acid base, and fluid balance. However, given that dialysis may not always provide a survival benefit nor improved quality of life in certain subpopulations, there is growing recognition of the need for conservative and preservative management as an alternative treatment strategy for advanced chronic kidney disease (CKD). Personalized nutritional management tailored to patient's sociodemographics, social needs, psychological status, health literacy level, and preferences is a key component of conservative and preservative care, as well as in the management of patients transitioning from non-dialysis dependent CKD to dialysis. In this review, we discuss the nutritional and metabolic alterations that ensue in CKD; the rationale for low-protein diets in the conservative and preservative management of advanced CKD; the role of plant-based diets in kidney health; emerging data on dietary potassium and sodium intake on CKD outcomes; and the practical implementation of dietary interventions in advanced kidney disease.
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Affiliation(s)
- Yoko Narasaki
- Division of Nephrology, Hypertension, and Kidney Transplantation, Department of Medicine, University of California Irvine, Orange, CA, USA
- Tibor Rubin Veterans Affairs Long Beach Healthcare System, Long Beach, CA, USA
| | - Man Kit Siu
- Division of Nephrology, Hypertension, and Kidney Transplantation, Department of Medicine, University of California Irvine, Orange, CA, USA
- Tibor Rubin Veterans Affairs Long Beach Healthcare System, Long Beach, CA, USA
| | - Matthew Nguyen
- Division of Nephrology, Hypertension, and Kidney Transplantation, Department of Medicine, University of California Irvine, Orange, CA, USA
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology, Hypertension, and Kidney Transplantation, Department of Medicine, University of California Irvine, Orange, CA, USA
- Tibor Rubin Veterans Affairs Long Beach Healthcare System, Long Beach, CA, USA
- The Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Connie M Rhee
- Division of Nephrology, Hypertension, and Kidney Transplantation, Department of Medicine, University of California Irvine, Orange, CA, USA
- Tibor Rubin Veterans Affairs Long Beach Healthcare System, Long Beach, CA, USA
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2
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Yin O, Coscia L, Constantinescu S, Moritz MJ, Afshar Y, Irani RA. Pregnancy after deceased donor vs living donor kidney transplant: associated obstetric and graft outcomes. Am J Obstet Gynecol 2024; 230:256.e1-256.e12. [PMID: 37595824 DOI: 10.1016/j.ajog.2023.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 07/21/2023] [Accepted: 08/11/2023] [Indexed: 08/20/2023]
Abstract
BACKGROUND Outside of pregnancy, recipients of a deceased donor kidney transplant experience worse graft and overall survival compared with recipients of a living donor kidney transplant. In pregnancy, it is unknown whether the type of donor graft modifies either graft health in the peripartum period or pregnancy outcomes. OBJECTIVE This study aimed to define characteristics and outcomes in pregnancy based on donor type in kidney transplant recipients. STUDY DESIGN This was a retrospective cohort study of adult kidney transplant recipients who received their graft between 2000 and 2019 with a subsequent pregnancy enrolled in the Transplant Pregnancy Registry International. The primary outcome was graft loss within 2 years of delivery. The secondary outcomes included severe maternal morbidity and neonatal composite morbidity. Univariate, multivariable logistic regression, and Cox proportional-hazards models were constructed for statistical analysis, with recipients of a living unrelated donor as the referent. RESULTS Overall, 638 pregnant patients after kidney transplant had pregnancy outcomes that met our inclusion criteria. Of these patients, 168 (26.3%) received a graft from a deceased donor, 310 (48.6%) received a graft from a living related donor, and 160 (25.1%) received a graft from a living unrelated donor. Recipients of a deceased donor were more likely to be nulliparous, have an unplanned pregnancy, and self-identify as non-White. Moreover, recipients of a deceased donor were more likely to experience urinary tract infections (deceased donor: 21.8%; living related donor: 10.1%; living unrelated donor: 20.6%; P=.018). Severe maternal morbidity (deceased donor: 3.4%; living related donor: 2.8%; living unrelated donor: 7.2%) and neonatal composite morbidity (deceased donor: 8.4%; living related donor: 17.1%; living unrelated donor: 14.4%) did not differ by donor type. Deceased donor transplant was associated with graft loss within 2 years of delivery (deceased donor: 6.7%; living related donor: 3.7%; living unrelated donor: 1.3%; adjusted odds ratio, 7.52; 95% confidence interval, 1.53-60.8) and long-term graft loss from transplant (adjusted hazard ratio, 2.08; 95% confidence interval, 1.10-3.95). CONCLUSION Although our study demonstrated an association between deceased donor transplant and graft loss after pregnancy, it did not provide evidence that pregnancy itself causes graft loss. Recipients of a deceased donor kidney transplant should not be discouraged from pursuing pregnancy based on their donor type, but these patients should undergo preconception counseling with a discussion of their individualized obstetrical and graft risks, close intrapartum monitoring for infection and hypertensive disease, and continued surveillance for at least 2 years after delivery with a multidisciplinary obstetrics and transplant team.
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Affiliation(s)
- Ophelia Yin
- Division of Maternal-Fetal Medicine and Reproductive Genetics, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA
| | - Lisa Coscia
- Transplant Pregnancy Registry International (TPRI), Gift of Life Institute, Philadelphia, PA
| | - Serban Constantinescu
- Transplant Pregnancy Registry International (TPRI), Gift of Life Institute, Philadelphia, PA; Section of Nephrology, Hypertension, and Kidney Transplantation, Department of Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, PA
| | - Michael J Moritz
- Transplant Pregnancy Registry International (TPRI), Gift of Life Institute, Philadelphia, PA
| | - Yalda Afshar
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA; Molecular Biology Institute, University of California, Los Angeles, Los Angeles, CA
| | - Roxanna A Irani
- Division of Maternal-Fetal Medicine and Reproductive Genetics, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA.
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3
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Parajuli S, Garonzik-Wang J, Astor BC, Aziz F, Garg N, Welch B, Odorico J, Mezrich J, Kaufman D, Foley DP, Mandelbrot D. Twelve Thousand Kidney Transplants Over More Than 55 Y: A Single-center Experience. Transplant Direct 2024; 10:e1575. [PMID: 38264296 PMCID: PMC10803012 DOI: 10.1097/txd.0000000000001575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 10/31/2023] [Accepted: 11/12/2023] [Indexed: 01/25/2024] Open
Abstract
Background Kidney transplant outcomes have dramatically improved since the first successful transplant in 1954. In its early years, kidney transplantation was viewed more skeptically. Today it is considered the treatment of choice among patients with end-stage kidney disease. Methods Our program performed its first kidney transplant in 1966 and recently performed our 12 000th kidney transplant. Here, we review and describe our experience with these 12 000 transplants. Transplant recipients were analyzed by decade of date of transplant: 1966-1975, 1976-1985, 1986-1995, 1996-2005, 2006-2015, and 2016-2022. Death-censored graft failure and mortality were outcomes of interest. Results Of 12 000 kidneys, 247 were transplanted from 1966 to 1975, 1147 from 1976 to 1985, 2194 from 1986 to 1995, 3147 from 1996 to 2005, 3046 from 2006 to 2015, and 2219 from 2016 to 2022 compared with 1966-1975, there were statistically significant and progressively lower risks of death-censored graft failure at 1 y, 5 y, and at last follow-up in all subsequent eras. Although mortality at 1 y was lower in all subsequent eras after 1986-1995, there was no difference in mortality at 5 y or the last follow-up between eras. Conclusions In this large cohort of 12 000 kidneys from a single center, we observed significant improvement in outcomes over time. Kidney transplantation remains a robust and ever-growing and improving field.
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Affiliation(s)
- Sandesh Parajuli
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
- UW Health Transplant Center, Madison, WI
| | - Jacqueline Garonzik-Wang
- UW Health Transplant Center, Madison, WI
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Brad C. Astor
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Fahad Aziz
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
- UW Health Transplant Center, Madison, WI
| | - Neetika Garg
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
- UW Health Transplant Center, Madison, WI
| | - Bridget Welch
- UW Health Transplant Center, Madison, WI
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Jon Odorico
- UW Health Transplant Center, Madison, WI
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Joshua Mezrich
- UW Health Transplant Center, Madison, WI
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Dixon Kaufman
- UW Health Transplant Center, Madison, WI
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - David P. Foley
- UW Health Transplant Center, Madison, WI
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Didier Mandelbrot
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
- UW Health Transplant Center, Madison, WI
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4
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Zulkhash N, Shanazarov N, Kissikova S, Kamelova G, Ospanova G. Review of prognostic factors for kidney transplant survival. Urologia 2023; 90:611-621. [PMID: 37350238 DOI: 10.1177/03915603231183754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/24/2023]
Abstract
Transplantation is the most effective treatment for end-stage chronic kidney disease, as this procedure prolongs and improves the patient's quality of life. One of the key problems is the risk of graft rejection. The purpose of this research was to identify and analyse prognostic factors that will prevent rejection. In particular, the prognostic factors grouped by methods of synthesis, generalisation and statistical processing with calculation and graphical representation of hazard ratio and correlation coefficient were grouped, namely: age of donor and recipient, time of cold kidney ischaemia, duration of preoperative dialysis, body mass index, presence of concomitant diseases (diabetes mellitus, hypertension), primary causes causing transplantation. Several molecular genetic and biochemical prognostic markers (transcription factors, immunocompetent cell signalling and receptors, cytostatin C, creatinine, citrate, lactate, etc.) are annotated. It has been demonstrated that creatinine reduction rate determines the risk of rejection, displaying the dynamics of cystatin C and creatinine changes in the postoperative period. Young recipients who underwent prolonged preoperative dialysis were identified as having the highest risk of rejection. Diabetes and hypertension bear a non-critical but commensurately equal risk of rejection. The survival rate of the graft is better when transplanted from a living donor than from a deceased donor. A correlation between cold ischaemia time, body mass index and the probability of graft failure has been proven, namely, the greater the donor and recipient body mass index and the longer the cold ischaemia time, the lower the chance of successful long-term organ acclimation. The data obtained can be used as prognostic factors for graft accommodation at different intervals after surgery.
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Affiliation(s)
- Nargiz Zulkhash
- Department of Public Health, Astana Medical University, Astana, Republic of Kazakhstan
| | - Nasrulla Shanazarov
- Department of Strategic Development, Science and Education, Medical Center Hospital of the President's Affairs Administration of the Republic of Kazakhstan, Astana, Republic of Kazakhstan
| | - Saule Kissikova
- Medical Center of the President's Affairs Administration of the Republic of Kazakhstan, Astana, Republic of Kazakhstan
| | - Guldauren Kamelova
- Department of Otorhinolaryngology and Ophthalmology, West Kazakhstan Marat Ospanov Medical University, Aktobe, Republic of Kazakhstan
| | - Gulzhaina Ospanova
- Department of Otorhinolaryngology and Ophthalmology, West Kazakhstan Marat Ospanov Medical University, Aktobe, Republic of Kazakhstan
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5
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Crespo MM, Samra M, Korsun A, Butler L, Byford H, Tietjen A, Stillion L, Ohler L, Mehta S. Collaborative leadership in transplantation: Blending clinical, business, and regulatory roles. Clin Transplant 2023; 37:e15126. [PMID: 37747969 DOI: 10.1111/ctr.15126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 08/16/2023] [Accepted: 09/05/2023] [Indexed: 09/27/2023]
Abstract
Transplantation is a high-risk, high-cost treatment for end-stage diseases and is the most strictly regulated area of healthcare in the United States. Thus, achieving success for patients and the program requires skillful and collaborative leadership. Various factors, such as outcomes, volume, and financial health, may measure the success of a transplant program. Strong collaboration between clinical and administrative leaders is key to achieving and maintaining success in those three categories. Clinical leaders of adult programs, such as medical and surgical directors, bear the primary responsibility for a program's volume, outcomes, and patient safety, while administrative directors are focused on business intelligence and regulatory compliance. This paper aims to provide readers with insights into the critical role of collaborative leadership in running a successful program, with a focus on clinical, business, and regulatory perspectives.
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Affiliation(s)
- Maria M Crespo
- Division of Pulmonary, Allergy, and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Manpreet Samra
- Kidney Transplant Program, Edward Hines Jr VA Hospital, Hines, Illinois, USA
| | | | | | | | - Andrea Tietjen
- Cooperman Barnabas Medical Center, Livingston, New Jersey, USA
| | | | - Linda Ohler
- George Washington University, Washington, District of Columbia, USA
| | - Shikha Mehta
- Kidney Transplant Program, University of Alabama, Birmingham, Alabama, USA
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6
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Wang JH, Hart A. Global Perspective on Kidney Transplantation: United States. KIDNEY360 2021; 2:1836-1839. [PMID: 35373000 PMCID: PMC8785833 DOI: 10.34067/kid.0002472021] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 08/18/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Jeffrey H. Wang
- Department of Medicine, Hennepin Healthcare, Minneapolis, Minnesota,Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Allyson Hart
- Department of Medicine, Hennepin Healthcare, Minneapolis, Minnesota,Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
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7
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Poggio ED, Augustine JJ, Arrigain S, Brennan DC, Schold JD. Long-term kidney transplant graft survival-Making progress when most needed. Am J Transplant 2021; 21:2824-2832. [PMID: 33346917 DOI: 10.1111/ajt.16463] [Citation(s) in RCA: 93] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 11/23/2020] [Accepted: 12/15/2020] [Indexed: 02/06/2023]
Abstract
Current short-term kidney post-transplant survival rates are excellent, but longer-term outcomes have historically been unchanged. This study used data from the national Scientific Registry of Transplant Recipients (SRTR) and evaluated 1-year and 5-year graft survival and half-lives for kidney transplant recipients in the US. All adult (≥18 years) solitary kidney transplants (n = 331,216) from 1995 to 2017 were included in the analysis. Mean age was 49.4 years (SD +/-13.7), 60% male, and 25% Black. The overall (deceased and living donor) adjusted hazard of graft failure steadily decreased from 0.89 (95%CI: 0.88, 0.91) in era 2000-2004 to 0.46 (95%CI: 0.45, 0.47) for era 2014-2017 (1995-1999 as reference). Improvements in adjusted hazards of graft failure were more favorable for Blacks, diabetics and older recipients. Median survival for deceased donor transplants increased from 8.2 years in era 1995-1999 to an estimated 11.7 years in the most recent era. Living kidney donor transplant median survival increased from 12.1 years in 1995-1999 to an estimated 19.2 years for transplants in 2014-2017. In conclusion, these data show continuous improvement in long-term outcomes with more notable improvement among higher-risk subgroups, suggesting a narrowing in the gap for those disadvantaged after transplantation.
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Affiliation(s)
- Emilio D Poggio
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio.,Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Joshua J Augustine
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio.,Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Susana Arrigain
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio.,Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Daniel C Brennan
- Division of Nephrology, Johns Hopkins University, Baltimore, Maryland
| | - Jesse D Schold
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio.,Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio.,Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
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8
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Gardezi AI, Muth B, Ghaffar A, Aziz F, Garg N, Mohamed M, Foley D, Kaufman D, Djamali A, Mandelbrot D, Parajuli S. Continuation of Peritoneal Dialysis in Adult Kidney Transplant Recipients With Delayed Graft Function. Kidney Int Rep 2021; 6:1634-1641. [PMID: 34169204 PMCID: PMC8207463 DOI: 10.1016/j.ekir.2021.03.899] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 03/11/2021] [Accepted: 03/29/2021] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Peritoneal dialysis (PD) has been used increasingly in past decade. Many of these patients undergo transplantation and may require dialysis for delayed graft function (DGF). The outcomes of DGF based on the post-transplantation dialysis modality are not well known. METHODS We retrospectively reviewed all adult kidney transplant recipients (KTRs) from the University of Wisconsin School of Medicine and Public Health who developed DGF between November 2015 and April 2019. Patients were divided into those who received hemodialysis (HD) or PD during the DGF period. Immediate graft explant, DGF among living donor KTRs, or those requiring just a single dialysis treatment were excluded. RESULTS Of 224 KTRs with DGF during the study period, 167 fulfilled our selection criteria. There were 16 patients in the PD and 151 in the HD group. Baseline characteristics were similar between the two groups, except diabetes was more prevalent in the HD group. Five of 16 PD patients had to be transitioned to HD. There was no difference in DGF duration, hospital length of stay, infectious or surgical complications, rejection at various time periods, graft function at last follow-up, or graft failure. In multivariate analysis, only rejection within the first year of transplantation (hazard ratio [HR]: 4.26; 95% confidence interval [CI]: 1.20-15.08; P = 0.02) and post-surgical complications (HR: 3.79; 95% CI: 1.03- 13.91; P = 0.04) were associated with death-censored graft failure (DCGF). The use of PD for treatment of DGF was not associated with DCGF. CONCLUSIONS In carefully selected patients, PD can be continued safely for DGF without any effect on short-term or long-term transplant outcomes.
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Affiliation(s)
- Ali I. Gardezi
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Brenda Muth
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Adil Ghaffar
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Fahad Aziz
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Neetika Garg
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Maha Mohamed
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - David Foley
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Dixon Kaufman
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Arjang Djamali
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Didier Mandelbrot
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Sandesh Parajuli
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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9
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Schold JD, Mohan S, Huml A, Buccini LD, Sedor JR, Augustine JJ, Poggio ED. Failure to Advance Access to Kidney Transplantation over Two Decades in the United States. J Am Soc Nephrol 2021; 32:913-926. [PMID: 33574159 PMCID: PMC8017535 DOI: 10.1681/asn.2020060888] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 12/02/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Extensive research and policies have been developed to improve access to kidney transplantation among patients with ESKD. Despite this, wide variation in transplant referral rates exists between dialysis facilities. METHODS To evaluate the longitudinal pattern of access to kidney transplantation over the past two decades, we conducted a retrospective cohort study of adult patients with ESKD initiating ESKD or placed on a transplant waiting list from 1997 to 2016 in the United States Renal Data System. We used cumulative incidence models accounting for competing risks and multivariable Cox models to evaluate time to waiting list placement or transplantation (WLT) from ESKD onset. RESULTS Among the study population of 1,309,998 adult patients, cumulative 4-year WLT was 29.7%, which was unchanged over five eras. Preemptive WLT (prior to dialysis) increased by era (5.2% in 1997-2000 to 9.8% in 2013-2016), as did 4-year WLT incidence among patients aged 60-70 (13.4% in 1997-2000 to 19.8% in 2013-2016). Four-year WLT incidence diminished among patients aged 18-39 (55.8%-48.8%). Incidence of WLT was substantially lower among patients in lower-income communities, with no improvement over time. Likelihood of WLT after dialysis significantly declined over time (adjusted hazard ratio, 0.80; 95% confidence interval, 0.79 to 0.82) in 2013-2016 relative to 1997-2000. CONCLUSIONS Despite wide recognition, policy reforms, and extensive research, rates of WLT following ESKD onset did not seem to improve in more than two decades and were consistently reduced among vulnerable populations. Improving access to transplantation may require more substantial interventions.
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Affiliation(s)
- Jesse D. Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio,Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University Vagelos College of Physicians & Surgeons, New York, New York,Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
| | - Anne Huml
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Laura D. Buccini
- Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - John R. Sedor
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Emilio D. Poggio
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
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10
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Malavade TS, Dey A, Chan CT. Nocturnal Hemodialysis: Why Aren't More People Doing It? Adv Chronic Kidney Dis 2021; 28:184-189. [PMID: 34717866 DOI: 10.1053/j.ackd.2021.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 04/13/2021] [Indexed: 11/11/2022]
Abstract
Nocturnal hemodialysis is a form of intensive hemodialysis, which may be done in center or at home. Despite the documented clinical and economic benefits of ncturnal hemodialysis, uptake of this modality has been relatively low. In this review, we aim to address the potential barriers and possible mitigation strategies. Among the patient-related barriers, lack of knowledge and awareness remains the most common barrier, while administrative inertia to change from conventional in-center hemodialysis continues to be a challenge. Current global effort to grow home dialysis will re-focus the need for better patient education, innovate home dialysis technology, and evolve new models of care. New patient-focused policy will allow changes in reimbursement and develop appropriate momentum toward an integrated "home first model" to kidney replacement therapy.
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11
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Using Geographic Catchment Areas to Measure Population-based Access to Kidney Transplant in the United States. Transplantation 2020; 104:e342-e350. [PMID: 33215901 DOI: 10.1097/tp.0000000000003369] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Monitoring efforts to improve access to transplantation requires a definition of the population attributable to a transplant center. Previously, assessment of variation in transplant care has focused on differences between administrative units-such as states-rather than units derived from observed care patterns. We defined catchment areas (transplant referral regions [TRRs]) from transplant center care patterns for population-based assessment of transplant access. METHODS We used US adult transplant listings (2006-2016) and Dartmouth Atlas catchment areas to assess the optimal method of defining TRRs. We used US Renal Data System and Scientific Registry of Transplant Recipient data to compare waitlist- and population-based kidney transplant rates. RESULTS We identified 110 kidney, 67 liver, 85 pancreas, 68 heart, and 43 lung TRRs. Most patients were listed in their assigned TRR (kidney: 76%; liver: 75%; pancreas: 75%; heart: 74%; lung: 72%), although the proportion varied by organ (interquartile range for kidney, 65.7%-82.5%; liver, 58.2%-78.8%; pancreas, 58.4%-81.1%; heart, 63.1%-80.9%; lung, 61.6%-76.3%). Patterns of population- and waitlist-based kidney transplant rates differed, most notably in the Northeast and Midwest. CONCLUSIONS Patterns of TRR-based kidney transplant rates differ from waitlist-based rates, indicating that current metrics may not reflect transplant access in the broader population. TRRs define populations served by transplant centers and could enable future studies of how transplant centers can improve access for patients in their communities.
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12
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Abstract
PURPOSE OF REVIEW Deceased donation represents the largest supply of organs for transplant in the United States. Organs with suboptimal characteristics related to donor disease or recovery-related issues are increasingly discarded at the time of recovery, prompting late allocation to candidates later in the match sequence. Late allocation contributes to organ injury by prolonging cold ischemia, which may further lead to the risk of organ discard, despite the potential to provide benefit to certain transplant candidates. RECENT FINDINGS Expedited placement of marginal organs has emerged as a strategy to address the growing problem of organ discard of marginal organs that have been declined late after recovery. In this review, we describe the basis for expedited organ placement, and approaches to facilitating placement of these grafts, drawing examples from kidney and liver donation and transplantation globally. SUMMARY There is significant global variation in practice related to late allocation. Multiple policy mechanisms exist to facilitate expedited placement, including simultaneous offers to multiple centers, predesignation of aggressive centers, and increasing organ procurement organization autonomy in late allocation. Optimizing late allocation of deceased donor organs holds significant promise to increase the number of transplants.
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