World Kidney Day 2012: The Global Role of Kidney Transplantation

Global Epidemiology of End-Stage Kidney Disease and Disparities in Kidney Replacement Therapy

BACKGROUND

The global epidemiology of end-stage kidney disease (ESKD) reflects each nation's unique genetic, environmental, lifestyle, and sociodemographic characteristics. The response to ESKD, particularly regarding kidney replacement therapy (KRT), depends on local disease burden, culture, and socioeconomics. Here, we explore geographic variation and global trends in ESKD incidence and prevalence and examine variations in KRT modality, practice patterns, and mortality. We conclude with a discussion on disparities in access to KRT and strategies to reduce ESKD global burden and to improve access to treatment in low- and middle-income countries (LMICs).

SUMMARY

From 2003 to 2016, incidence rates of treated ESKD were relatively stable in many higher income countries but rose substantially predominantly in East and Southeast Asia. The prevalence of treated ESKD has increased worldwide, likely due to improving ESKD survival, population demographic shifts, higher prevalence of ESKD risk factors, and increasing KRT access in countries with growing economies. Unadjusted 5-year survival of ESKD patients on KRT was 41% in the USA, 48% in Europe, and 60% in Japan. Dialysis is the predominant KRT in most countries, with hemodialysis being the most common modality. Variations in dialysis practice patterns account for some of the differences in survival outcomes globally. Worldwide, there is a greater prevalence of KRT at higher income levels, and the number of people who die prematurely because of lack of KRT access is estimated at up to 3 times higher than the number who receive treatment. Key Messages: Many people worldwide in need of KRT as a life-sustaining treatment do not receive it, mostly in LMICs where health care resources are severely limited. This large treatment gap demands a focus on population-based prevention strategies and development of affordable and cost-effective KRT. Achieving global equity in KRT access will require concerted efforts in advocating effective public policy, health care delivery, workforce capacity, education, research, and support from the government, private sector, nongovernmental, and professional organizations.

Infection-Related Mortality in Recipients of a Kidney Transplant in Australia and New Zealand

BACKGROUND AND OBJECTIVES

The burden of infectious disease is high among kidney transplant recipients because of concomitant immunosuppression. In this study the incidence of infectious-related mortality and associated factors were evaluated.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

In this registry-based retrospective, longitudinal cohort study, recipients of a first kidney transplant in Australia and New Zealand between 1997 and 2015 were included. Cumulative incidence of infectious-related mortality was estimated using competing risk regression (using noninfectious mortality as a competing risk event), and compared with age-matched, populated-based data using standardized incidence ratios.

RESULTS

Among 12,519 patients, (median age 46 years, 63% men, 15% diabetic, 6% Indigenous ethnicity), 2197 (18%) died, of whom 416 (19%) died from infection. The incidence of infection-related mortality during the study period (1997-2015) was 45.8 (95% confidence interval [95% CI], 41.6 to 50.4) per 10,000 patient-years. The incidence of infection-related mortality reduced from 53.1 (95% CI, 45.0 to 62.5) per 10,000 person-years in 1997-2000 to 43.9 (95% CI, 32.5 to 59.1) per 10,000 person-years in 2011-2015 (P<0.001) Compared with the age-matched general population, kidney transplant recipients had a markedly higher risk of infectious-related death (standardized incidence ratio, 7.8; 95% CI, 7.1 to 8.6). Infectious mortality was associated with older age (≥60 years adjusted subdistribution hazard ratio [SHR], 4.16; 95% CI, 2.15 to 8.05; reference 20-30 years), female sex (SHR, 1.62; 95% CI, 1.19 to 2.29), Indigenous ethnicity (SHR, 2.87; 95% CI, 1.84 to 4.46; reference white), earlier transplant era (2011-2015: SHR, 0.39; 95% CI, 0.20 to 0.76; reference 1997-2000), and use of T cell-depleting therapy (SHR, 2.43; 95% CI, 1.36 to 4.33). Live donor transplantation was associated with lower risk of infection-related mortality (SHR, 0.53; 95% CI, 0.37 to 0.76).

CONCLUSIONS

Infection-related mortality in kidney transplant recipients is significantly higher than the general population, but has reduced over time. Risk factors include older age, female sex, Indigenous ethnicity, T cell-depleting therapy, and deceased donor transplantation.

PODCAST

This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2019_08_27_CJN03200319.mp3.

Evaluation of Immunosuppressive Activity of Demethylzeylasteral in a Beagle Dog Kidney Transplantation Model

Several monomers isolated from Tripterygium wilfordii Hook f. (Celastraceae) have attracted worldwide interest. In this study, we established a simple and reliable kidney transplantation model in beagle dog to evaluate the immunosuppressive activity of demethylzeylasteral (T-96), an immunosuppressive monomer isolated from the root xylem of T. wilfordii. Recipient and donor male beagle dogs were obtained from two different breeders to ensure MHC mismatching. All dogs were randomly divided into six groups following kidney transplantation, and different doses of T-96 or cyclosporine A (CsA) were administered to each group during 14 days of observation. The results showed that T-96 alone at a dosage of 10 or 20 mg/kg/day prolonged graft survival up to 10.83 ± 1.47 or 11.17 ± 1.47 days. A combination of T-96 and CsA significantly prolonged the survival time to 13.33 ± 1.75 days. The results demonstrated that T-96 can inhibit acute rejection in kidney transplantation, and the inhibitory effect of T-96 was enhanced when combined with CsA, which suggests the possible use in organ transplantation to prevent immune rejection.

Chronic kidney disease in disadvantaged populations

The increased burden of chronic kidney disease (CKD) in disadvantaged populations is due to both global factors and population-specific issues. Low socioeconomic status and poor access to care contribute to health care disparities and exacerbate the negative effects of genetic or biological predisposition. Provision of appropriate renal care to these populations requires a two-pronged approach: expanding the reach of dialysis through development of low-cost alternatives that can be practiced in remote locations, and implementation and evaluation of cost-effective prevention strategies. Kidney transplantation should be promoted by expansion of deceased donor transplant programs and use of inexpensive, generic immunosuppressive drugs. The message of World Kidney Day 2015 is that a concerted attack against the diseases that lead to end-stage renal disease, by increasing community outreach, better education, improved economic opportunity, and access to preventive medicine for those at highest risk, could end the unacceptable relationship between CKD and disadvantage in these communities.

The Effect of Health Promotion Strategies Education on Self-Care Self-Efficacy in Patients Undergoing Kidney Transplantation: A Double Blind Randomized Trial

Background:

Self-care self-efficacy in patients with end stage renal disease, waiting for kidney transplantation, probably decreases due to facing new conditions and side effects of treatment.

Objectives:

The current study was conducted to investigate the effect of educating health promotion strategies on self-care self-efficacy in patients undergoing kidney transplantation.

Patients and Methods:

A double blind randomized clinical trial was conducted on 52 patients undergoing kidney transplantation in Baqiyatallah Hospital in 2012. Patients were randomly assigned into intervention and control groups. The questionnaire of Strategies Used by People to Promote Health (SUPPH) was employed to measure self-care self-efficacy. At first, the two groups filled the questionnaire. Then, the intervention group was trained regarding health promotion strategies within 4 sessions before the transplantation. The control group was trained according to routine protocol of the transplantation unit. Then, the two groups were followed up for two months, and reassessed at the end of the first and second months after the transplantation. The data were analyzed by descriptive and analytic statistics including independent samples T test, Chi square and repeated measures ANOVA.

Results:

In the intervention group, the mean of total self-care self-efficacy was 106.96 ± 25.1 at first, and changed to 135.81 ± 9.65 and 111.19 ± 12.45 after the first and second post-test respectively (P = 0.001). In the control group, the mean of total self-care self-efficacy was 112.73 ± 14.33 at first, and changed to 118.58 ± 17.59 and 108.73 ± 15.93 after the first and second post-test respectively (P = 0.001). Significant differences were observed between the two groups in the first post-test regarding total score of self-care self-efficacy (P = 0.001) and dimensions of reduction of stress (P = 0.001), enjoying life (P = 0.01), and coping (P = 0.001). The mean scores of the intervention group were higher than those of the controls in all domains of self-care self-efficacy in the second post-test. However, the difference was only significant in decision-making dimension (P = 0.04).

Conclusions:

Educating health promotion strategies was effective in improving self-care self-efficacy in patients undergoing kidney transplantation. Establishment of a holistic caring program is suggested to integrate the pre-transplantation educations with a continual post discharge follow-up.