Patient and allograft survival of Indo Asian and East Asian dialysis patients treated in Canada

Navigating Living Kidney Donation and Transplantation Among South Asian Canadians: The ACTION Project

RATIONALE & OBJECTIVE

South Asian (SA) Canadians with kidney failure have a 50%-77% lower likelihood of kidney transplant and are less likely to identify potential living donors (LDs). This study aimed to identify health system-, patient-, and community-level barriers and facilitators for accessing LD kidney transplantation in the SA community to inform the development of health system- and community-level interventions to address barriers.

STUDY DESIGN

Qualitative study.

SETTING & PARTICIPANTS

20 SA recipients of an LD or deceased-donor kidney transplant, 10 SA LDs, and 41 general SA community members.

ANALYTICAL APPROACH

In-depth multilingual interviews were conducted with recipients and LDs. Gender-, language-, and age-stratified focus groups were conducted with general SA community members. Summative content analysis was used to analyze the data.

RESULTS

Hesitancy in approaching potential donors, fear about the health of potential LDs, information gaps, language barriers, and challenges evaluating out-of-country donors were highlighted as significant barriers by recipients, and financial concerns and information gaps were identified by donors. Cultural barriers in the SA community were highlighted by donors, recipients, and community members as critical factors when considering donation and transplant; women and elderly SA Canadians highlighted nuanced challenges. Participants reported generally a favorable perception of their health care teams, citing SA representation in the teams as important to providing culturally and linguistically sensitive care.

LIMITATIONS

Limited geographic, race, and cultural representation and reliance on virtual data collection.

CONCLUSIONS

This study highlights several culturally relevant barriers to donation and transplant that are potentially modifiable through patient-, health system-, and community-focused engagement and education.

"Weighing the Pros and Cons of Everything": A Qualitative Descriptive Study Exploring Perspectives About Living Donor Kidney Transplantation From Parents of Chinese Canadian Pediatric Patients With Chronic Kidney Disease

Background

As of 2021, more than 6000 children and youth in Canada were living with end-stage kidney disease (ESKD), for which kidney transplantation is considered the preferred treatment by health professionals. Research shows that living donor kidney transplantation (LDKT) has superior allograft and recipient survival compared to deceased donor kidney transplantation (DDKT). However, in a pediatric setting, the choice of LDKT or DDKT is a summative consideration of factors weighed carefully by the patient's family, health care team, and patient. Decision-making surrounding transplantation may be more complex for racial and ethnic minorities as culturally specific values and beliefs are interwoven within dominant understandings and concepts of health and accepted models of health care. For example, Chinese Canadians have an increased risk of ESKD, yet reduced access to LDKT compared to White patients, despite being the largest visible minority population in Canada.

Objective

The objective of this qualitative study is to deepen our understandings of the decision-making process surrounding DDKT versus LDKT among parents of Chinese Canadian pediatric patients with chronic kidney disease (CKD).

Design

Qualitative descriptive study design.

Setting

The Nephrology Program at The Hospital for Sick Children in Toronto, Canada.

Participants

Caregivers of Chinese Canadian patients with CKD, 18 years of age or older, and who spoke English, Cantonese, or Mandarin.

Methods

One-on-one, semistructured interviews were conducted virtually, by a member of the research team and were audio-recorded and transcribed verbatim. Thematic analysis was used to explore participants' shared experience.

Results

Seven interviews were conducted with 6 mothers and 1 father of 6 Chinese Canadian pediatric patients with CKD: 4 patients had undergone a kidney transplant, and 2 were not yet listed for transplant. Analysis of data highlighted that cultural influences affected whether parents shared with others about their child's illness and experience. The cultural understanding that it is inappropriate to burden others contributed to the creation of an isolating experience for participants. Cultural influences also impacted whether parents asked others to be a living donor as participants articulated this would place a physical burden on the living donor (e.g., potential risk to their health) and an emotional burden on the participant as they would be indebted to a willing donor. Ultimately, parents' decision to choose DDKT or LDKT for their patient-child was a result of evaluating both options carefully and within an understanding that the ideal treatment choice reflected what was best for all family members.

Limitations

Findings reflect experiences of a small sample from a single recruitment site which may limit transferability.

Conclusions

Parents in this study felt that they had access to the necessary evidence-based information to make an informed decision about the choice of DDKT versus LDKT for their child. Participant narratives described feeling isolated within cultural communities of family and friends and participants' suggestion of benefiting from increased support may guide future research directions. Practitioners can offer direct and indirect support to families, with recognition of the importance of cultural values and family-centered care on decision-making within families. Opportunities are needed for accessible, virtual social support platforms to increase parental feelings of culturally mediated peer support from parents who share similar experiences.

Pretransplant Patient Education in Solid-organ Transplant: A Narrative Review

Education for pretransplant, solid-organ recipient candidates aims to improve knowledge and understanding about the transplant process, outcomes, and potential complications to support informed, shared decision-making to reduce fears and anxieties about transplant, inform expectations, and facilitate adjustment to posttransplant life. In this review, we summarize novel pretransplant initiatives and approaches to educate solid-organ transplant recipient candidates. First, we review approaches that may be common to all solid-organ transplants, then we summarize interventions specific to kidney, liver, lung, and heart transplant. We describe evidence that emphasizes the need for multidisciplinary approaches to transplant education. We also summarize initiatives that consider online (eHealth) and mobile (mHealth) solutions. Finally, we highlight education initiatives that support racialized or otherwise marginalized communities to improve equitable access to solid-organ transplant. A considerable amount of work has been done in solid-organ transplant since the early 2000s with promising results. However, many studies on education for pretransplant recipient candidates involve relatively small samples and nonrandomized designs and focus on short-term surrogate outcomes. Overall, many of these studies have a high risk of bias. Frequently, interventions assessed are not well characterized or they are combined with administrative and data-driven initiatives into multifaceted interventions, which makes it difficult to assess the impact of the education component on outcomes. In the future, well-designed studies rigorously assessing well-defined surrogate and clinical outcomes will be needed to evaluate the impact of many promising initiatives.

Elderly kidney transplant recipients have favorable outcomes but increased infection-related mortality

Background

The number of elderly patients with end-stage kidney disease has been increasing, but the outcomes of kidney transplants (KT) remain poorly understood in elderly patients. Therefore, we evaluated the clinical outcomes of elderly KT recipients and analyzed the impact of elderly donors.

Methods

This retrospective cohort study included patients who underwent KT between 2000 and 2019. KT recipients were divided into four groups according to a combination of recipient and donor age (≥60 or <60 years); elderly recipients: old-to-old (n = 46) and young-to-old (n = 83); young recipients: old-to-young (n = 98) and young-to-young (n = 796). We compared the risks of mortality, graft failure, and acute rejection between groups using Cox regression analysis.

Results

The incidence of delayed graft function, graft failure, and acute rejection was not different among groups. Annual mean tacrolimus trough level was not lower in elderly recipients than young recipients during 10-year follow-up. Mortality was significantly higher in elderly recipients (p = 0.001), particularly infection-related mortality (p < 0.001). In multivariable Cox regression analysis, old-to-old and young-to-old groups had increased risk of mortality (adjusted hazard ratio [aHR], 2.89; 95% confidence interval [CI], 1.14–7.32; p = 0.03; aHR, 3.06; 95% CI, 1.51–6.20; p = 0.002). However, graft failure and acute rejection risks were not increased in elderly recipients.

Conclusion

In elderly recipients, graft survival and acute rejection-free survival were not inferior to those of young recipients. However, mortality, especially risk of infection-related death, was increased in elderly recipients. Thus, low immunosuppression intensity might help decrease mortality in elderly recipients.

Managing cardiovascular disease risk in South Asian kidney transplant recipients

South Asians (SA) are at higher cardiovascular risk than other ethnic groups, and SA kidney transplant recipients (SA KTR) are no exception. SA KTR experience increased major adverse cardiovascular events both early and late post-transplantation. Cardiovascular risk management should therefore begin well before transplantation. SA candidates may require aggressive screening for pre-transplant cardiovascular disease (CVD) due to their ethnicity and comorbidities. Recording SA ethnicity during the pre-transplant evaluation may enable programs to better assess cardiovascular risk, thus allowing for earlier targeted peri- and post-transplant intervention to improve cardiovascular outcomes. Diabetes remains the most prominent post-transplant cardiovascular risk factor in SA KTR. Diabetes also clusters with other metabolic syndrome components including lower high-density lipoprotein cholesterol, higher triglycerides, hypertension, and central obesity in this population. Dyslipidemia, metabolic syndrome, and obesity are all significant CVD risk factors in SA KTR, and contribute to increased insulin resistance. Novel biomarkers such as adiponectin, apolipoprotein B, and lipoprotein (a) may be especially important to study in SA KTR. Focused interventions to improve health behaviors involving diet and exercise may especially benefit SA KTR. However, there are few interventional clinical trials specific to the SA population, and none are specific to SA KTR. In all cases, understanding the nuances of managing SA KTR as a distinct post-transplant group, while still screening for and managing each CVD risk factor individually in all patients may help improve the long-term success of all kidney transplant programs catering to multi-ethnic populations.

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

BACKGROUND

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

OBJECTIVE

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

ELIGIBILITY CRITERIA

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

SOURCES OF EVIDENCE

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

CHARTING METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

Validation of Self-Reported Race in a Canadian Provincial Renal Administrative Database

Background:

Administrative data are commonly used to study clinical outcomes in renal disease. Race is an important determinant of renal health delivery and outcomes in Canada but is not validated in most administrative data, and the correlation with census-based definitions of race is unknown.

Objectives:

Validation of self-reported race (SRR) in a Canadian provincial renal administrative database (Patient Records and Outcome Management Information System [PROMIS]) and comparison with the Canadian census categories of race.

Design:

Prospective patient survey study to validate SRR in PROMIS.

Setting:

British Columbia, Canada.

Patients:

Adult patients registered in PROMIS.

Measurements:

Survey SRR was used as gold standard to validate SRR in PROMIS. Self-reported race in PROMIS was compared with census race categories.

Methods:

This is a cross-sectional telephone survey of a random sample of all adults in PROMIS conducted between February 2016 and November 2016. Responders selected a race category from PROMIS and from the Canadian census. Sensitivity (Sn) and specificity (Sp) were calculated with 95% confidence intervals (CIs).

Results:

A total of 21 039 patients met inclusion criteria, 1677 were selected for the survey and 637 participated (38% response rate). There were no differences between the PROMIS, sampled, and responder populations. PROMIS SRR had an accuracy of 95.3% (95% CI: 94.2%-97.0%) when validated against the survey SRR with Sn and Sp ≥90% in all race groups except in Aboriginals (Sn 87.5%). The positive and negative predictive values were ≥95%, except in very low and high–prevalence groups, respectively. The Canadian census had an accuracy of 95.7% (95% CI: 94.4%-97.6%) when validated against PROMIS SRR with Sn and Sp ≥90%. The results did not differ in subgroups based on age, sex, birth outside Canada, or renal group (glomerulonephritis, chronic kidney disease, hemodialysis, peritoneal dialysis, transplant recipients, or live donors).

Limitations:

Analysis of minority groups and lower prevalence groups is limited by sample size. Results may not be generalizable to other administrative databases.

Conclusions:

We have shown high accuracy of PROMIS SRR that validates its use in the secondary analysis of administrative data for research. There is high correlation between PROMIS and census race categories which allows linkage with other data sources that use census-based definitions of race.

Ethnic background is associated with no live kidney donor identified at the time of first transplant assessment-an opportunity missed? A single-center retrospective cohort study

Patients from ethnocultural minorities have reduced access to live donor kidney transplant (LDKT). To explore early pretransplant ethnocultural disparities in LDKT readiness, and the impact of the interactions with the transplant program, we assessed if patients had a potential live donor (LD) identified at first pretransplant assessment, and if patients with no LD initially received LDKT subsequently. Single-center, retrospective cohort of adults referred for kidney transplant (KT) assessment. Multivariable logistic regression assessed the association between ethnicity and having a potential LD. Cox proportional hazard analysis assessed the association between no potential LD initially and subsequent LDKT. Of 1617 participants, 66% of Caucasians indicated having a potential LD, compared with 55% of South Asians, 44% of African Canadians, and 41% of East Asians (P < 0.001). In multivariable logistic regression analysis, the odds of having a potential LD identified was significantly lower for African, East and South Asian Canadians. No potential LD at initial KT assessment was associated with lower likelihood of LDKT subsequently (hazard ratio [HR], 0.14; [0.10-0.19]). Compared to Caucasians, African, East and South Asian and African Canadians are less likely to have a potential LD identified at first KT assessment, which predicts a lower likelihood of subsequent LDKT.

Inequalities and outcomes: end stage kidney disease in ethnic minorities

Background

The international evidence about outcomes of End Stage Kidney Disease (ESKD) for ethnic minorities was reviewed to identify gaps and make recommendations for researchers and policy makers.

Methods

Nine databases were searched systematically with 112 studies from 14 different countries included and analysed to produce a thematic map of the literature.

Results

Reviews (n = 26) highlighted different mortality rates and specific causes between ethnic groups and by stage of kidney disease associated with individual, genetic, social and environmental factors. Primary studies focussing on uptake of treatment modalities (n = 19) found ethnic differences in access. Research evaluating intermediate outcomes and quality of care in different treatment phases (n = 35) e.g. dialysis adequacy, transplant evaluation and immunosuppression showed ethnic minorities were disadvantaged. This is despite a survival paradox for some ethnic minorities on dialysis seen in studies of longer term outcomes (n = 29) e.g. in survival time post-transplant and mortality. There were few studies which focussed on end of life care (n = 3) and ethnicity.

Gaps identified were: limited evidence from all stages of the ESKD pathway, particularly end of life care; a lack of system oriented studies with a reliance on national routine datasets which are limited in scope; a dearth of qualitative studies; and a lack studies from many countries with limited cross country comparison and learning.

Conclusions

Differences between ethnic groups occur at various points and in a variety of outcomes throughout the kidney care system. The combination of individual factors and system related variables affect ethnic groups differently indicating a need for culturally intelligent policy informed by research to prevent disadvantage.

Reduced Tacrolimus Trough Level Is Reflected by Estimated Glomerular Filtration Rate (eGFR) Changes in Stable Renal Transplantation Recipients: Results of the OPTIMUM Phase 3 Randomized Controlled Study

Background

Minimizing the tacrolimus dosage in patients with stable allograft function needs further investigation.

Material/Methods

We performed an open-label, randomized, controlled study from 2010 to 2016 in 7 tertiary teaching hospitals in Korea and enrolled 345 kidney transplant recipients with a stable graft status. The study group received reduced-dose tacrolimus, 1080–1440 mg/day of enteric-coated mycophenolate sodium (EC-MPS), and corticosteroids. The control group received the standard tacrolimus dosage and 540–720 mg/day of EC-MPS with steroids. The primary endpoint was the mean estimated glomerular filtration rate (eGFR) and change in the eGFR at 12 months after randomization.

Results

The mean tacrolimus trough level of the study group was 4.51±1.62 ng/mL, which was lower than that of the control group, at 6.75±2.82 ng/mL (P<0.001). The primary endpoint was better in the study group in terms of change in eGFR (P<0.001). The month 12 eGFRs were 73.6±28.4 and 68.3±18.1 mL/min/1.73 m² in the study and the control groups, respectively, but the difference did not reach statistical significance (P=0.07). The incidence of adverse events was similar between the study and the control groups.

Conclusions

Minimizing tacrolimus to a trough level below 5 ng/mL combined with conventional EC-MPS can be considered in patients with a steady follow-up, as it was associated with small benefits in the changes of the eGFR (Clinicaltrials.gov number: NCT01159080).

Ethnic Background Is a Potential Barrier to Living Donor Kidney Transplantation in Canada: A Single-Center Retrospective Cohort Study

BACKGROUND

We examined if African or Asian ethnicity was associated with lower access to kidney transplantation (KT) in a Canadian setting.

METHODS

Patients referred for KT to the Toronto General Hospital from January 1, 2003, to December 31, 2012, who completed social work assessment, were included (n = 1769). The association between ethnicity and the time from referral to completion of KT evaluation or receipt of a KT were examined using Cox proportional hazards models.

RESULTS

About 54% of the sample was white, 13% African, 11% East Asian, and 11% South Asian; 7% had "other" (n = 121) ethnic background. African Canadians (hazard ratio [HR], 0.75; 95% CI: 0.62-0.92]) and patients with "other" ethnicity (HR, 0.71; 95% CI, 0.55-0.92) were less likely to complete the KT evaluation compared with white Canadians, and this association remained statistically significant in multivariable adjusted models. Access to KT was significantly reduced for all ethnic groups assessed compared with white Canadians, and this was primarily driven by differences in access to living donor KT. The adjusted HRs for living donor KT were 0.35 (95% CI, 0.24-0.51), 0.27 (95% CI, 0.17-0.41), 0.43 (95% CI, 0.30-0.61), and 0.34 (95% CI, 0.20-0.56) for African, East or South Asian Canadians and for patients with "other" ethnic background, respectively.

CONCLUSIONS

Similar to other jurisdictions, nonwhite patients face barriers to accessing KT in Canada. This inequity is very substantial for living donor KT. Further research is needed to identify if these inequities are due to potentially modifiable barriers.

Survival and transplantation outcomes of children less than 2 years of age with end-stage renal disease

BACKGROUND

Young children with end-stage renal disease (ESRD) requiring renal replacement therapy (RRT) have traditionally experienced high rates of morbidity and mortality; however, detailed long-term follow-up data is limited.

METHODS

Using a population-based retrospective cohort with data from a national organ failure registry and administrative data from Canada's universal health care system, we analysed the outcomes of 87 children starting RRT (before age 2 years) and followed them until death or date of last contact [median follow-up 4.7 years, interquartile range (IQR) 1.4-9.8). We assessed secular trends in survival and the influence of: (1) age at start of RRT and (2) etiology of ESRD with survival and time to transplantation.

RESULTS

Patients were mostly male (69.0 %) with ESRD predominantly due to renal malformations (54.0 %). Peritoneal dialysis was the most common initial RRT (83.9 %). Fifty-seven (65.5 %) children received a renal transplant (median age at first transplant: 2.7 years, IQR 2.0-3.3). During 490 patient-years of follow-up, there were 23 (26.4 %) deaths, of which 22 occurred in patients who had not received a transplant. Mortality was greater for patients commencing dialysis between 1992 and 1999 and among the youngest children starting RRT (0-3 months). Children with ESRD secondary to renal malformations had better survival than those with ESRD due to other causes. Among the transplanted patients, all but one survived to the end of the observation period.

CONCLUSION

Children who start RRT before 3 months of age have a high risk of mortality. Among our paediatric patient cohort, mortality rates were much lower among children who had received a renal transplant.

Social deprivation, ethnicity, and uptake of living kidney donor transplantation in the United Kingdom

BACKGROUND

Socioeconomic disparities and their contribution to the ethnic differences in living kidney donor transplantation have not been adequately studied.

METHODS

A total of 12,282 patients aged 18 to 69 years starting renal replacement therapy (January 1, 1997, to December 31, 2004) in the United Kingdom were included. Logistic regression models were used to examine probability of living donor transplantation within 3 years of renal replacement therapy. The effect of area deprivation (Townsend index) was studied among whites only adjusted for patient characteristics and the effect of ethnic origin (South Asians and blacks compared with whites) was then examined among all patients adjusting for area deprivation.

RESULTS

Among whites, increasing social deprivation was associated with lower odds of living donor transplantation. In the fully adjusted model, odds ratio (OR) for the most deprived quintile was 0.40 (95% confidence interval [CI] 0.33, 0.49; P trend<0.0001) compared with the least deprived. These gradients were more pronounced among centers performing more live donor transplants (P value for interaction <0.0001). South Asians and blacks had lower odds of living donor transplantation compared with whites, but there was an interaction with age (P<0.0001), so that this disparity was observed only in those younger than 50 years (blacks: OR, 0.31; 95% CI, 0.18, 0.54; South Asians: OR, 0.55; 95% CI, 0.34, 0.90; P value <0.0001).

CONCLUSIONS

Socially deprived and younger ethnic minority patients have lower probability of living kidney donor transplantation. The extent to which these inequalities reflect modifiable societal healthcare system barriers and donor/recipient factors requires further study.

Identifying depression in South asian patients with end-stage renal disease: considerations for practice

Depression is a prevalent burden for patients with end-stage renal disease (ESRD) and one that is under-recognized and consequently under-treated. Although several studies have explored the association between depression symptoms, treatment adherence and outcomes in Euro-American patient groups, quantitative and qualitative exploration of these issues in patients from different cultural and ethnic backgrounds has been lacking. This review discusses the methodological issues associated with measuring depression in patients of South Asian origin who have a 3- to 5-fold greater risk of developing ESRD. There is a need to advance research into the development of accurate screening practices for this patient group, with an emphasis on studies utilizing rigorous approaches to evaluating the use of both emic (culture-specific) and etic (universal or culture-general) screening instruments.

Graft failure and adaptation period to adult healthcare centers in pediatric renal transplant patients

BACKGROUND

Transfer from pediatric to adult care may require a period of adaptation to the new healthcare environment. We sought to determine whether this adaptation period was associated with an increased risk of graft failure.

METHODS

Children (age, 0-18 years) recorded in the Canadian Organ Replacement Register who received a first kidney transplant in a pediatric health center between 1992 and 2007, and who had more than or equal to 3 months of graft function, were followed up until death, loss to follow-up, or December 31, 2007. Cox proportional hazards models were used to estimate the excess risk associated with a period of adaptation to adult-oriented care, defined as the interval 0.5 years before to 2.5 years after the first recorded adult care visit. Models were adjusted for age, gender, donor source, and ethnicity.

RESULTS

Of the 413 patients evaluated, 149 were transferred to adult care during study period. In total, 78 (18.9%) patients experienced graft failure-23 during the adaptation period. Compared with the period before adaptation, the adjusted hazard ratio for graft loss within the adaptation period was 2.24 (95% confidence interval [CI]: 1.19-4.20). The adjusted graft failure rate was 2.26 (1.04-4.93) times higher after 18 years of age than between 0 and 13 years. Aboriginal ethnicity and deceased donor source were also associated with a significantly higher risk of graft failure.

CONCLUSIONS

The period of adaptation to adult-oriented care is associated with a high risk of graft failure in pediatric renal transplant patients.

Attitudes and opinions on organ donation: an opportunity to educate in a Canadian city

BACKGROUND

Patients on organ transplant waiting lists continue to far exceed donor rates. We seek to understand the barriers preventing people in a Canadian city from donating organs for transplantation.

METHODS

One thousand adults were surveyed assessing knowledge, personal involvement, and attitudes about organ donation in an urban center in Canada. Primary outcomes of interest were a signed organ donor card and willingness to donate.

RESULTS

Of those surveyed, 64% did not realize that they possessed an organ donor card; 90% would consider being a donor if a friend was in need of an organ. Of the 36% who did know, 72% had signed it. Those who had misconceptions about the organ donation process were less likely to be donors.

INTERPRETATION

There is a tremendous lack of knowledge about organ donation. While the majority of people are interested in organ donation, they lack a means to express this interest - most do not even realize they possess an organ donor card. A significant proportion of people who were not supportive of donation were misinformed in critical areas of knowledge that likely influenced this decision including the rich being preferentially transplanted, the consent process, disfigurement, and donors receiving worse medical care.

South Asian ethnicity as a risk factor for major adverse cardiovascular events after renal transplantation

BACKGROUND AND OBJECTIVES

South Asians (SAs) comprise 25% of all Canadian visible minorities. SAs constitute a group at high risk for cardiovascular disease in the general population, but the risk in SA kidney transplant recipients has never been studied.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

In a cohort study of 864 kidney recipients transplanted from 1998 to 2007 and followed to June 2009, we identified risk factors including ethnicity associated with major cardiac events (MACEs, a composite of nonfatal myocardial infarction, coronary intervention, and cardiac death) within and beyond 3 months after transplant. Kaplan-Meier methodology and multivariate Cox regression analysis were used to determine risk factors for MACEs.

RESULTS

There was no difference among SAs (n = 139), whites (n = 550), blacks (n = 65), or East Asians (n = 110) in baseline risk, including pre-existing cardiac disease. Post-transplant MACE rate in SAs was 4.4/100 patient-years compared with 1.31, 1.16, and 1.61/100 patient-years in whites, blacks, and East Asians, respectively (P < 0.0001 versus each). SA ethnicity independently predicted MACEs along with age, male gender, diabetes, systolic BP, and prior cardiac disease. SAs also experienced more MACEs within 3 months after transplant compared with whites (P < 0.0001), blacks (P = 0.04), and East Asians (P = 0.006). However, graft and patient survival was similar to other groups.

CONCLUSIONS

SA ethnicity is an independent risk factor for post-transplant cardiac events. Further study of this high-risk group is warranted.

Chronic kidney disease in kidney transplant recipients-is it different from chronic native kidney disease?

BACKGROUND

The rate of change in estimated glomerular filtration rate (ΔeGFR), factors influencing ΔeGFR, and its association with mortality has not been well studied in renal transplant recipients. METHODS.: Adult kidney-only recipients between January 2001 and December 2004, with surviving grafts 1 year after transplantation, from England and Wales were followed up till 31 December 2006, graft failure or death. The four variable modification of diet in renal disease equation was used to estimate GFR and ΔeGFR assessed using linear least square regression. ΔeGFR of -1 mL/min/1.73m per year and above was considered to be stable or improving function. Linear regression and Cox regression analyses were used to examine factors influencing ΔeGFR and its association with mortality, respectively.

RESULTS

Of the 2, 927 patients included, ΔeGFR was -1.3±6.0 mL/min/1.73 m per year and eGFR remained stable or improved in the majority (54.8%). Baseline graft function at 1 year or live donor status did not influence ΔeGFR. Male donor to female recipient transplantation, younger recipients, diabetes, white race, and human leukocyte antigen mismatch were associated with faster decline in eGFR. ΔeGFR was not associated with mortality when censored for graft failure.

CONCLUSIONS

Majority of renal transplant recipients experienced stable or improved graft function. Specific donor and recipient characteristics influenced the rate of decline in eGFR. The lack of association of ΔeGFR with mortality, the stability of eGFR in the majority, and influence of donor characteristics on ΔeGFR suggest caution when applying prognosis knowledge from the native kidney disease to the kidney transplant population.

Overview of the Canadian pediatric end-stage renal disease database

BACKGROUND

Performing clinical research among pediatric end-stage renal disease patients is challenging. Barriers to successful initiation and completion of clinical research projects include small sample sizes and resultant limited statistical power and lack of longitudinal follow-up for hard clinical end-points in most single center studies.

DESCRIPTION

Existing longitudinal organ failure disease registry and administrative health datasets available within a universal access health care system can be used to study outcomes of end-stage renal disease among pediatric patients in Canada. To construct the Canadian Pediatric End-Stage Renal Disease database, registry data were linked to administrative health data through deterministic linkage techniques creating a research database which consists of socio-demographic variables, clinical variables, all-cause hospitalizations, and relevant outcomes (death and renal allograft loss) for this patient population. The research database also allows study of major cardiovascular events using previously validated administrative data definitions.

CONCLUSION

Organ failure registry linked to health administrative data can be a powerful tool to perform longitudinal studies in pediatric end-stage renal disease patients. The rich clinical and demographic information found in this database will facilitate study of important medical and non-medical risk factors for death, graft loss and cardiovascular disease among pediatric end-stage renal disease patients.

Ethnically diverse populations and their participation in living kidney donation programs

BACKGROUND

The number of living donor kidney transplantations increases steeply in Europeans, whereas the non-Europeans are dependent on deceased donor transplantations. We wondered whether a low attendance or a high decline of potential non-European donors could explain this difference.

METHODS

This retrospective study includes all 1059 potential living kidney donors who attended our pretransplant clinic between 2000 and 2007. Potential donors were divided according to eight countries of origin: African, Dutch Antillean, European, Indonesian, Moroccan, Surinamese, Turkish, and various countries. In addition to direct living donation, alternative living donation programs are operational in our center: kidney exchange, domino paired, ABO incompatible, and anonymous donation.

RESULTS

European donors predominated in both the potential (79%) and the actual donor populations (85%). Actual donors comprised 39% of non-European and 59% of the European potential donors (P<0.001). Participation in alternative donation programs is significantly less among non-European donors in comparison with European donors (3.6% vs. 12.6%, P<0.001). In all non-European populations, genetically related donors predominated, whereas genetically related and unrelated donors were equally represented in the European potential donor population (P<0.001). Partners were under-represented in all non-European populations (P<0.001). The attitude and behavior of non-Europeans with the longest duration of stay in the Netherlands were closest to that of the Europeans. The population with the shortest stay differed the most. This could possibly be attributed to integration.

CONCLUSION

There are less non-European donors than expected based on the population composition. Living donor characteristics are different between Europeans and non-Europeans. The reasons for the difference deserve investigation.

An Overview of Transplantation in Culturally Diverse Regions

Transplantation is one of the most progressive areas of medicine. Following its rapid development, organ transplantation has become part of the globalisation process, and is now available in all corners of the world in different social and cultural environments. Almost a decade into a new century, transplantation faces new challenges, with record numbers of patients on the waiting list, a scarcity of donor organs, inequity in access to transplantation, organ commercialisation, increasing living donation and the use of marginal donors. Probably more than in any other field of medicine, the cultural influences are very prominent in transplantation due to the complexity of the process and the ethical issues surrounding every step from donation, access to transplantation to outcome. These influences have led to different practical approaches around the world, which aim to be in agreement with the respective societal principles and moral values. Herein, we provide an overview of some of these challenges and their possible resolution in culturally diverse areas of the world. Key words: Access to transplantation, Living donor, Organ donation, Religion, Transplant laws, Transplant tourism

Deceased organ donation in Canada: an opportunity to heal a fractured system

There has been no significant increase in the number of deceased organ donors in Canada over the past decade. Canada's donation and transplant system will be restructured with the formation of a new national organization to oversee activity in provincially governed donation and transplantation services. We review the current status of deceased organ donation, highlight issues contributing to the current stagnation in donation and identify changes that will enable success in a new Canadian system. Determining Canada's organ donation performance is difficult because the data required to calculate meaningful metrics of donation performance are not available. Canadians wait longer for transplantation than Americans, and Canada is falling further behind the United States primarily because of fewer donations after cardiac death. The ongoing divide between intergovernmental jurisdictional domains limits national initiatives to improve Canada's donation system. The success of a new national system will be enabled by uniform provincial legislation to ensure that all patients are offered the option to donate, commitment of resources to support organ donation by provincial governments, transparent reporting of comparable metrics of donation performance, establishment of processes to introduce and implement new initiatives and alterations to reimbursement models for organ donation and recovery.

Ethical issues in the care of vulnerable chronic kidney disease patients: the elderly, cognitively impaired, and those from different cultural backgrounds

Numerous ethical issues such as the appropriate initiation or withdrawal of dialysis are inherent when one cares for patients with chronic kidney disease (CKD). Conflicts concerning decisions to withhold or withdraw dialysis often involve particularly vulnerable CKD patients such as the elderly, those with cognitive impairment, or those who come from different cultural backgrounds. Issues related to renal replacement therapy in vulnerable or special CKD populations will be explored within an ethical framework based on the principles of autonomy (self-determination), beneficence (to maximize good), nonmaleficence (to not cause harm), and justice (what is due or owed).

Renal transplantation for ethnic minorities in Canada: inequity in access and outcomes?

Among Canadians starting dialysis, patients of East Asian and Indo Asian background are less likely than whites to receive a renal allograft. Although the reasons for such variation are complex, less living donation may contribute significantly. More studies are needed to confirm these differences and to evaluate strategies for improving live kidney donation rates in communities at risk for low transplantation rates.