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Savige J. Tips for Testing Adults With Suspected Genetic Kidney Disease. Am J Kidney Dis 2024; 83:816-824. [PMID: 38147894 DOI: 10.1053/j.ajkd.2023.10.011] [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: 04/10/2023] [Revised: 10/08/2023] [Accepted: 10/14/2023] [Indexed: 12/28/2023]
Abstract
Genetic kidney disease is common but often unrecognized. It accounts for most cystic kidney diseases and tubulopathies, many forms of congenital abnormalities of the kidney and urinary tract (CAKUT), and some glomerulopathies. Genetic kidney disease is typically suspected where the disease usually has a genetic basis or there is another affected family member, a young age at onset, or extrarenal involvement, but there are also many exceptions to these "rules". Genetic testing requires the patient's written informed consent. When a patient declines testing, another later conversation may be worthwhile. Genetic testing not only indicates the diagnosis but also the inheritance pattern, likely at-risk family members, disease in other organs, clinical course, and possibly effective treatments. Sometimes genetic testing does not identify a pathogenic variant even where other evidence is strong. A variant of uncertain significance (VUS) may be reported but should not be used for clinical decision making. It may be reclassified after more information becomes available without necessarily retesting the patient. Patients should be provided with a copy of their genetic test report, the results explained, and at-risk family members offered "cascade" testing. A referral to a clinical geneticist or genetic counselor helps identify affected family members and in providing advice to assist with reproductive decisions.
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Affiliation(s)
- Judy Savige
- University of Melbourne Department of Medicine (Melbourne Health and Northern health), Royal Melbourne Hospital, Parkville, Australia.
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2
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McIntosh T, Walsh H, Baldwin K, Iltis A, Mohan S, Sawinski D, Goodman M, DuBois JM. Evaluating ApoL1 Genetic Testing Policy Options for Transplant Centers: A Delphi Consensus Panel Project with Stakeholders. Clin J Am Soc Nephrol 2024; 19:494-502. [PMID: 38190141 PMCID: PMC11020447 DOI: 10.2215/cjn.0000000000000397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 12/26/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND Apolipoprotein L1 (ApoL1) variants G1 and G2 are associated with a higher risk of kidney disease. ApoL1 risk variants are predominantly seen in individuals with sub-Saharan African ancestry. In most transplant centers, potential organ donors are being selectively genetically tested for ApoL1 risk variants. Transplant programs have highly variable ApoL1 testing practices and need guidance on essential ApoL1 clinical policy questions. METHODS We conducted a Delphi consensus panel focused on ApoL1 clinical policy questions, including who gets tested, who decides whether testing occurs, how test results are shared, who receives test results, and how test results are used. A total of 27 panelists across seven stakeholder groups participated: living kidney donors ( n =4), deceased donor family members ( n =3), recipients of a deceased donor kidney ( n =4), recipients of a living donor kidney ( n =4), nephrologists ( n =4), transplant surgeons ( n =4), and genetic counselors ( n =4). Nineteen panelists (70%) identified as Black. The Delphi panel process involved two rounds of educational webinars and three rounds of surveys administered to panelists, who were asked to indicate whether they support, could live with, or oppose each policy option. RESULTS The panel reached consensus on one or more acceptable policy options for each clinical policy question; panelists supported 18 policy options and opposed 15. Key elements of consensus include the following: ask potential donors about African ancestry rather than race; make testing decisions only after discussion with donors; encourage disclosure of test results to blood relatives and organ recipients but do not require it; use test results to inform decision making, but never for unilateral decisions by transplant programs. CONCLUSIONS The panel generally supported policy options involving discussion and shared decision making among patients, donors, and family stakeholders. There was general opposition to unilateral decision making and prohibiting donation altogether.
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Affiliation(s)
- Tristan McIntosh
- Bioethics Resaerch Center, Washington University School of Medicine, St. Louis, Missouri
| | - Heidi Walsh
- Bioethics Resaerch Center, Washington University School of Medicine, St. Louis, Missouri
| | - Kari Baldwin
- Bioethics Resaerch Center, Washington University School of Medicine, St. Louis, Missouri
| | - Ana Iltis
- Center for Bioethics, Health and Society, Wake Forest University, Winston-Salem, North Carolina
| | - Sumit Mohan
- Mailman School of Public Health, Columbia University, New York, New York
| | | | - Melody Goodman
- School of Global Public Health, New York University, New York, New York
| | - James M. DuBois
- Bioethics Resaerch Center, Washington University School of Medicine, St. Louis, Missouri
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3
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McElroy LM, Schappe T, Mohottige D, Davis L, Peskoe SB, Wang V, Pendergast J, Boulware LE. Racial Equity in Living Donor Kidney Transplant Centers, 2008-2018. JAMA Netw Open 2023; 6:e2347826. [PMID: 38100105 PMCID: PMC10724764 DOI: 10.1001/jamanetworkopen.2023.47826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 10/30/2023] [Indexed: 12/18/2023] Open
Abstract
Importance It is unclear whether center-level factors are associated with racial equity in living donor kidney transplant (LDKT). Objective To evaluate center-level factors and racial equity in LDKT during an 11-year time period. Design, Setting, and Participants A retrospective cohort longitudinal study was completed in February 2023, of US transplant centers with at least 12 annual LDKTs from January 1, 2008, to December 31, 2018, identified in the Health Resources Services Administration database and linked to the US Renal Data System and the Scientific Registry of Transplant Recipients. Main Outcomes and Measures Observed and model-based estimated Black-White mean LDKT rate ratios (RRs), where an RR of 1 indicates racial equity and values less than 1 indicate a lower rate of LDKT of Black patients compared with White patients. Estimated yearly best-case center-specific LDKT RRs between Black and White individuals, where modifiable center characteristics were set to values that would facilitate access to LDKT. Results The final cohorts of patients included 394 625 waitlisted adults, of whom 33.1% were Black and 66.9% were White, and 57 222 adult LDKT recipients, of whom 14.1% were Black and 85.9% were White. Among 89 transplant centers, estimated yearly center-level RRs between Black and White individuals accounting for center and population characteristics ranged from 0.0557 in 2008 to 0.771 in 2018. The yearly median RRs ranged from 0.216 in 2016 to 0.285 in 2010. Model-based estimations for the hypothetical best-case scenario resulted in little change in the minimum RR (from 0.0557 to 0.0549), but a greater positive shift in the maximum RR from 0.771 to 0.895. Relative to the observed 582 LDKT in Black patients and 3837 in White patients, the 2018 hypothetical model estimated an increase of 423 (a 72.7% increase) LDKTs for Black patients and of 1838 (a 47.9% increase) LDKTs for White patients. Conclusions and Relevance In this cohort study of patients with kidney failure, no substantial improvement occurred over time either in the observed or the covariate-adjusted estimated RRs. Under the best-case hypothetical estimations, modifying centers' participation in the paired exchange and voucher programs and increased access to public insurance may contribute to improved racial equity in LDKT. Additional work is needed to identify center-level and program-specific strategies to improve racial equity in access to LDKT.
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Affiliation(s)
- Lisa M. McElroy
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Tyler Schappe
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Dinushika Mohottige
- Institute of Health Equity Research and Barbara T. Murphy Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - LaShara Davis
- Department of Surgery and J. C. Walter Jr Transplant Center, Houston Methodist Hospital, Houston, Texas
| | - Sarah B. Peskoe
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Virginia Wang
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Jane Pendergast
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - L. Ebony Boulware
- Wake Forest University School of Medicine, Winston Salem, North Carolina
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Stein Q, Westemeyer M, Darwish T, Pitman T, Hager M, Tabriziani H, Curry K, Collett K, Raible D, Hendricks E. Genetic Counseling in Kidney Disease: A Perspective. Kidney Med 2023; 5:100668. [PMID: 37334143 PMCID: PMC10276256 DOI: 10.1016/j.xkme.2023.100668] [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] [Indexed: 06/20/2023] Open
Abstract
As genetic testing is increasingly integrated into nephrology practice there is a growing need for partnership with genetic experts. Genetic counselors are ideally suited to fill this role. The value of genetic counseling is born out of the clinical value of genetic test results against the backdrop of the complexity of genetic testing. Genetic counselors who specialize in nephrology are trained to understand and explain the potential effects of genes on kidney disease, which can enable patients to make informed decisions about proceeding with genetic testing, navigating variants of uncertain significance, educating on extrarenal features of hereditary kidney disease, facilitating cascade testing, providing post-test education about testing results, and assisting with family planning. Genetic counselors can partner with the nephrologist and provide the knowledge needed to maximize the use of genetic testing for patients for nephrology consultation. Genetic counseling is more than an element or extension of genetic testing; it is a dynamic, shared conversation between the patient and the genetic counselor where concerns, sentiments, information, and education are exchanged, and value-based decision making is facilitated.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Darbey Raible
- St. Elizabeth Healthcare Precision Medicine, Edgewood, KY
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Smith JD, Agrawal A, Wicklund C, Duquette D, Friedewald J, Rasmussen LV, Gacki-Smith J, Tandon SD, Muhammad LN, Yancy CW, Dong S, Cooper M, Gilbert A, Shetty A, Gordon EJ. Implementation of a culturally competent APOL1 genetic testing programme into living donor evaluation: A two-site, non-randomised, pre-post trial design. BMJ Open 2023; 13:e067657. [PMID: 37188469 PMCID: PMC10186444 DOI: 10.1136/bmjopen-2022-067657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 04/14/2023] [Indexed: 05/17/2023] Open
Abstract
INTRODUCTION While living donor (LD) kidney transplantation is the optimal treatment for patients with kidney failure, LDs assume a higher risk of future kidney failure themselves. LDs of African ancestry have an even greater risk of kidney failure post-donation than White LDs. Because evidence suggests that Apolipoprotein L1 (APOL1) risk variants contribute to this greater risk, transplant nephrologists are increasingly using APOL1 genetic testing to evaluate LD candidates of African ancestry. However, nephrologists do not consistently perform genetic counselling with LD candidates about APOL1 due to a lack of knowledge and skill in counselling. Without proper counselling, APOL1 testing will magnify LD candidates' decisional conflict about donating, jeopardising their informed consent. Given cultural concerns about genetic testing among people of African ancestry, protecting LD candidates' safety is essential to improve informed decisions about donating. Clinical 'chatbots', mobile apps that provide genetic information to patients, can improve informed treatment decisions. No chatbot on APOL1 is available and no nephrologist training programmes are available to provide culturally competent counselling to LDs about APOL1. Given the shortage of genetic counsellors, increasing nephrologists' genetic literacy is critical to integrating genetic testing into practice. METHODS AND ANALYSIS Using a non-randomised, pre-post trial design in two transplant centres (Chicago, IL, and Washington, DC), we will evaluate the effectiveness of culturally competent APOL1 testing, chatbot and counselling on LD candidates' decisional conflict about donating, preparedness for decision-making, willingness to donate and satisfaction with informed consent and longitudinally evaluate the implementation of this intervention into clinical practice using the Reach, Effectiveness, Adoption, Implementation and Maintenance framework. ETHICS AND DISSEMINATION This study will create a model for APOL1 testing of LDs of African ancestry, which can be implemented nationally via implementation science approaches. APOL1 will serve as a model for integrating culturally competent genetic testing into transplant and other practices to improve informed consent. This study involves human participants and was approved by Northwestern University IRB (STU00214038). Participants gave informed consent to participate in the study before taking part. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04910867. Registered 8 May 2021, https://register. CLINICALTRIALS gov/prs/app/action/SelectProtocol?sid=S000AWZ6&selectaction=Edit&uid=U0001PPF&ts=7&cx=-8jv7m2 ClinicalTrials.gov Identifier: NCT04999436. Registered 5 November 2021, https://register. CLINICALTRIALS gov/prs/app/action/SelectProtocol?sid=S000AYWW&selectaction=Edit&uid=U0001PPF&ts=11&cx=9tny7v.
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Affiliation(s)
- Justin D Smith
- Department of Population Health Sciences, Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, Utah, USA
- Departments of Psychiatry and Behavioral Sciences and Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Akansha Agrawal
- Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Catherine Wicklund
- Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Debra Duquette
- Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - John Friedewald
- Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Luke V Rasmussen
- Division of Health and Biomedical Informatics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jessica Gacki-Smith
- Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - S Darius Tandon
- Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Lutfiyya N Muhammad
- Department of Preventive Medicine-Division of Biostatistics, Northwestern University, Chicago, Illinois, USA
| | - Clyde W Yancy
- Department of Medicine-Division of Cardiology, Northwestern University, Evanston, Illinois, USA
| | - Siyuan Dong
- Department of Preventive Medicine-Division of Biostatistics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Matthew Cooper
- Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Alexander Gilbert
- Medicine, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Aneesha Shetty
- Medicine, The University of Arizona College of Medicine Tucson, Tucson, Arizona, USA
| | - Elisa J Gordon
- Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Rivera FB, Ansay MFM, Golbin JM, Alfonso PGI, Mangubat GFE, Menghrajani RHS, Placino S, Taliño MKV, De Luna DV, Cabrera N, Trinidad CN, Kazory A. HIV-Associated Nephropathy in 2022. GLOMERULAR DISEASES 2022; 3:1-11. [PMID: 36816427 PMCID: PMC9936764 DOI: 10.1159/000526868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 08/22/2022] [Indexed: 02/24/2023]
Abstract
Background HIV-associated nephropathy (HIVAN) is a renal parenchymal disease that occurs exclusively in people living with HIV. It is a serious kidney condition that may possibly lead to end-stage kidney disease, particularly in the HIV-1 seropositive patients. Summary The African-American population has increased susceptibility to this comorbidity due to a strong association found in the APOL1 gene, specifically two missense mutations in the G1 allele and a frameshift deletion in the G2 allele, although a "second-hit" event is postulated to have a role in the development of HIVAN. HIVAN presents with proteinuria, particularly in the nephrotic range, as with other kidney diseases. The diagnosis requires biopsy and typically presents with collapsing subtype focal segmental glomerulosclerosis and microcyst formation in the tubulointerstitial region. Gaps still exist in the definitive treatment of HIVAN - concurrent use of antiretroviral therapy and adjunctive management with like renal-angiotensin-aldosterone system inhibitors, steroids, or renal replacement therapy showed benefits. Key Message This study reviews the current understanding of HIVAN including its epidemiology, mechanism of disease, related genetic factors, clinical profile, and pathophysiologic effects of management options for patients.
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Affiliation(s)
- Frederick Berro Rivera
- Department of Medicine, Lincoln Medical Center, New York, New York, USA,*Frederick Berro Rivera,
| | | | | | | | | | | | - Siena Placino
- St. Luke's Medical Center College of Medicine - William H. Quasha Memorial, Quezon City, Philippines
| | | | | | - Nicolo Cabrera
- Division of Infectious Diseases, George Washington University, Washington, District of Columbia, USA
| | - Carlo Nemesio Trinidad
- Section of Nephrology, University of the Philippines-Philippine General Hospital, Manila, Philippines
| | - Amir Kazory
- Division of Nephrology, Hypertension, and Renal Transplantation, University of Florida, Gainesville, Florida, USA
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Harris DD, Fleishman A, Pavlakis M, Pollak MR, Baliga PK, Rohan V, Kayler LK, Rodrigue JR. Apolipoprotein L1 Opinions of African American Living Kidney Donors, Kidney Transplant Patients, and Nonpatients. J Surg Res 2022; 277:116-124. [PMID: 35489216 DOI: 10.1016/j.jss.2022.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 02/03/2022] [Accepted: 04/06/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The discovery of apolipoprotein L1 (ApoL1) has raised important ethical and clinical questions about genetic testing in the context of living and deceased kidney donation. Largely missing from this discussion are the perspectives of those African Americans (AA) most likely to be impacted by ApoL1 testing. METHODS We surveyed 331 AA potential and former living kidney donors (LKDs), kidney transplant candidates and recipients, and nonpatients at three United States transplant programs about their ApoL1 testing attitudes. RESULTS Overall, 72% felt that transplant programs should offer ApoL1 testing to AA potential LKDs. If a potential LKD has the high-risk genotype, 79% felt that the LKD should be allowed to make their own donation decision or participate in shared decision-making with transplant doctors. More than half of the potential LKDs (58%) would undergo ApoL1 testing and 81% of former LKDs would take the test now if offered. Most transplant candidates expressed a low likelihood of accepting a kidney from a LKD (79%) or a deceased donor (67%) with the high-risk genotype. CONCLUSIONS There is strong support among LKDs and transplant patients for ApoL1 testing when evaluating potential kidney donors of African ancestry. Inclusion of AA stakeholders in developing guidelines and educational programs for ApoL1 testing is critical.
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Affiliation(s)
- Dwight D Harris
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Aaron Fleishman
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Martha Pavlakis
- Department of Surgery, Harvard Medical School, Boston, Massachusetts; Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Martin R Pollak
- Department of Surgery, Harvard Medical School, Boston, Massachusetts; Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Prabhakar K Baliga
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Vinayak Rohan
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Liise K Kayler
- Department of Surgery, University at Buffalo (SUNY) Jacobs School of Medicine & Biomedical Sciences and Erie County Medical Center, Buffalo, New York
| | - James R Rodrigue
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts; Department of Surgery, Medical University of South Carolina, Charleston, South Carolina.
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Nestor JG, Li AJ, King KL, Husain SA, McIntosh TJ, Sawinski D, Iltis AS, Goodman MS, Walsh HA, DuBois JM, Mohan S. Impact of education on APOL1 testing attitudes among prospective living kidney donors. Clin Transplant 2022; 36:e14516. [PMID: 34661305 PMCID: PMC9113661 DOI: 10.1111/ctr.14516] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 10/05/2021] [Accepted: 10/11/2021] [Indexed: 12/22/2022]
Abstract
It is unknown how providing prospective living donors with information about APOL1, including the benefits and drawbacks of testing, influences their desire for testing. In this study, we surveyed 102 participants with self-reported African ancestry and positive family history of kidney disease, recruited from our nephrology waiting room. We assessed views on APOL1 testing before and after presentation of a set of potential benefits and drawbacks of testing and quantified the self-reported level of influence individual benefits and drawbacks had on participants' desire for testing in the proposed context of living donation. The majority of participants (92%) were aware of organ donation and more than half (56%) had considered living donation. And though we found no significant change in response following presentation of the potential benefits and the drawbacks of APOL1 testing by study end significance, across all participants, "becoming aware of the potential risk of kidney disease among your immediate family" was the benefit with the highest mean influence (3.3±1.4), while the drawback with the highest mean influence (2.9±1.5) was "some transplant centers may not allow you to donate to a loved one". This study provides insights into the priorities of prospective living donors and suggests concern for how the information affects family members may strongly influence desires for testing. It also highlights the need for greater community engagement to gain a deeper understanding of the priorities that influence decision making on APOL1 testing.
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Affiliation(s)
- Jordan G. Nestor
- Department of Medicine, Division of Nephrology, Columbia University, New York, New York, USA
| | - Amber J. Li
- Department of Medicine, Division of Nephrology, Columbia University, New York, New York, USA
| | - Kristen L. King
- Department of Medicine, Division of Nephrology, Columbia University, New York, New York, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - S. Ali Husain
- Department of Medicine, Division of Nephrology, Columbia University, New York, New York, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA
| | - Tristan J. McIntosh
- Bioethics Research Center, Division of General Medical Sciences, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Deirdre Sawinski
- Department of Medicine, Renal Electrolyte and Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ana S. Iltis
- Center for Bioethics Health and Society and Department of Philosophy, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Melody S. Goodman
- School of Global Public Health, New York University, New York, New York, USA
| | - Heidi A. Walsh
- Bioethics Research Center, Division of General Medical Sciences, Washington University School of Medicine, St. Louis, Missouri, USA
| | - James M. DuBois
- Bioethics Research Center, Division of General Medical Sciences, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University, New York, New York, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA
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Arabi Z, Bukhari M, Hamad A, Altheaby A, Kaysi S. Practice Patterns in the Acceptance of Medically Complex Living Kidney Donors with Obesity, Hypertension, Family History of Kidney Disease, or Donor-Recipient Age Discrepancy. Avicenna J Med 2021; 11:172-184. [PMID: 34881200 PMCID: PMC8648409 DOI: 10.1055/s-0041-1736541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background
To assess the practice patterns of the acceptance of medically complex living kidney donors (MCLKDs).
Methods
We distributed a survey to nephrologists and transplant surgeons (TS) across the world through major international transplant societies. The survey contained questions regarding obesity, abnormal blood glucose profile, mild hypertension, donor-recipient age discrepancy, or family history of kidney disease of unknown etiology.
Results
In total, 239 respondents from 29 countries (42% were nephrologists and 58% were TS).
Most respondents would allow donations from obese donors, especially if they intended to lose weight but would be cautious if these donors had abnormal blood glucose or family history of diabetes mellitus. In hypertensive donors, future pregnancy plans mattered in decisions regarding the acceptance of female donors. Most respondents would allow young donors but would be more cautious if they had a future risk of hypertension or a family history of kidney disease of unknown etiology. They would also allow donations from an older person if prolonged waiting time was anticipated. We found multiple areas of consensus of practice among the diverse members of international transplant societies, with some interesting variations among nephrologists and TS. Conclusions
This survey highlights the practice patterns of the acceptance of MCLKDs among the international community. In the absence of clear guidelines, this survey provides additional information to counsel kidney donors with these conditions.
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Affiliation(s)
- Ziad Arabi
- Department of the Organ Transplant Center, Division of Adult Transplant Nephrology, King Abdulaziz Medical City, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Muhammad Bukhari
- Department of Medicine, Division of Adult Nephrology, Taif University, Taif, Saudi Arabia
| | - Abdullah Hamad
- Department of Medicine, Division of Nephrology, Regional Medical Center of Orangeburg and Calhoun Counties, Orangeburg, South Carolina, United States
| | - Abdulrahman Altheaby
- Department of the Organ Transplant Center, Division of Adult Transplant Nephrology, King Abdulaziz Medical City, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Saleh Kaysi
- Department of Medicine, Division of Nephrology, CHU, Clermont-Ferrand, France
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Iltis AS, Connell A, Cooper L, Gee PO, Jefferson NM, Johnson HA, Kingston GM, Roberts GV, Scott N, Smith A, Waddy S, Woodard L, DuBois JM. Improving Kidney Disease Research in the Black Community: The Essential Role of Black Voices in the APOLLO Study. Am J Kidney Dis 2021; 79:750-753. [PMID: 34653538 DOI: 10.1053/j.ajkd.2021.09.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 09/07/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Ana S Iltis
- Center for Bioethics, Health and Society, Wake Forest University, Winston-Salem, NC, USA.
| | | | | | | | | | | | | | | | | | | | | | | | - James M DuBois
- Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
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Thomas CP, Gupta S, Freese ME, Chouhan KK, Dantuma MI, Holanda DG, Katz DA, Darbro BW, Mansilla MA, Smith RJ. Sequential genetic testing of living-related donors for inherited renal disease to promote informed choice and enhance safety of living donation. Transpl Int 2021; 34:2696-2705. [PMID: 34632641 DOI: 10.1111/tri.14133] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 09/27/2021] [Accepted: 09/28/2021] [Indexed: 01/09/2023]
Abstract
Living kidney donors (LKDs) with a family history of renal disease are at risk of kidney disease as compared to LKDs without such history suggesting that some LKDs may be pre-symptomatic for monogenic kidney disease. LKDs with related transplant candidates whose kidney disease was considered genetic in origin were selected for genetic testing. In each case, the transplant candidate was first tested to verify the genetic diagnosis. A genetic diagnosis was confirmed in 12 of 24 transplant candidates (ADPKD-PKD1: 6, ALPORT-COL4A3: 2, ALPORT-COL4A5: 1: nephronophthisis-SDCCAG8: 1; CAKUT-HNF1B and ADTKD-MUC1: 1 each) and 2 had variants of unknown significance (VUS) in phenotype-relevant genes. Focused genetic testing was then done in 20 of 34 LKDs. 12 LKDs screened negative for the familial variant and were permitted to donate; seven screened positive and were counseled against donation. One, the heterozygous carrier of a recessive disorder was also cleared. Six of seven LKDs with a family history of ADPKD were under 30 years and in 5, by excluding ADPKD, allowed donation to safely proceed. The inclusion of genetic testing clarified the diagnosis in recipient candidates, improving safety or informed decision-making in LKDs.
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Affiliation(s)
- Christie P Thomas
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA.,Department of Pediatrics, University of Iowa, Iowa City, IA, USA.,Veterans Affairs Medical Center, Iowa City, IA, USA
| | - Sonali Gupta
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
| | - Margaret E Freese
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
| | | | - Maisie I Dantuma
- Iowa Institute of Human Genetics, University of Iowa, Iowa City, IA, USA
| | | | - Daniel A Katz
- Department of Surgery, University of Iowa, Iowa City, IA, USA
| | - Benjamin W Darbro
- Department of Pediatrics, University of Iowa, Iowa City, IA, USA.,Iowa Institute of Human Genetics, University of Iowa, Iowa City, IA, USA
| | - Maria A Mansilla
- Iowa Institute of Human Genetics, University of Iowa, Iowa City, IA, USA
| | - Richard J Smith
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA.,Department of Pediatrics, University of Iowa, Iowa City, IA, USA.,Iowa Institute of Human Genetics, University of Iowa, Iowa City, IA, USA
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12
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Abstract
PURPOSE OF REVIEW Living organ donation provides improved access to transplantation, thereby shortening transplant wait times and allowing for more deceased organ transplants. However, disparity in access to living donation has resulted in decreased rates of living donor transplants for some populations of patients. RECENT FINDINGS Though there have been marked improvements in deceased donor equity, there are still challenges as it relates to gender, racial/ethnic, and socio-economic disparity. Improvements in living donation rates in Hispanic and Asian populations are tempered by challenges in African American rates of organ donation. Socio-economic disparity may drive gender disparities in organ donation resulting in disproportionate female living donors. Tailored approaches relating to language-specific interventions as well as directed educational efforts have helped mitigate disparity. Additionally, the use of apolipoprotein1 testing and modifications of glomerular filtration rate calculators may improve rates of African American donation. This review will evaluate recent data in living donor disparity as well as highlight successes in mitigating disparity. SUMMARY Though there are still challenges in living donor disparity, many efforts at tailoring education and access as well as modifying living donor evaluation and identifying systemic policy changes may result in improvements in living donation rates.
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Affiliation(s)
- Reynold I Lopez-Soler
- Section of Renal Transplantation, Edward Hines VA Jr. Hospital, Hines
- Department of Surgery, Division of Intra-Abdominal Transplantation, Stritch School of Medicine, Maywood, Illinois, USA
| | - Raquel Garcia-Roca
- Department of Surgery, Division of Intra-Abdominal Transplantation, Stritch School of Medicine, Maywood, Illinois, USA
| | - David D Lee
- Department of Surgery, Division of Intra-Abdominal Transplantation, Stritch School of Medicine, Maywood, Illinois, USA
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13
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Doshi MD, Gordon EJ, Freedman BI, Glover C, Locke JE, Thomas CP. Integrating APOL1 Kidney-risk Variant Testing in Live Kidney Donor Evaluation: An Expert Panel Opinion. Transplantation 2021; 105:2132-2134. [PMID: 33534524 PMCID: PMC8994118 DOI: 10.1097/tp.0000000000003641] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Mona D. Doshi
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI
| | - Elisa J. Gordon
- Department of Surgery-Transplantation, Northwestern University, Chicago, IL
| | - Barry I. Freedman
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC
| | | | - Jayme E. Locke
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Christie P. Thomas
- Department of Medicine, University of Iowa, Iowa City, IA
- Department of Medicine, University of Iowa, Iowa City, IA
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14
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Freedman BI, Poggio ED. APOL1 genotyping in kidney transplantation: to do or not to do, that is the question? (pro). Kidney Int 2021; 100:27-30. [PMID: 34154719 DOI: 10.1016/j.kint.2020.11.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 09/05/2020] [Accepted: 11/19/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Barry I Freedman
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.
| | - Emilio D Poggio
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA
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15
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Outcomes of Living Kidney Donor Candidate Evaluations in the Living Donor Collective Pilot Registry. Transplant Direct 2021; 7:e689. [PMID: 33912656 PMCID: PMC8078331 DOI: 10.1097/txd.0000000000001143] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 01/16/2021] [Accepted: 02/01/2021] [Indexed: 11/25/2022] Open
Abstract
Supplemental Digital Content is available in the text. Background. Gaps in our knowledge of long-term outcomes affect decision making for potential living kidney donors. Methods. The Scientific Registry of Transplant Recipients was asked to determine the feasibility of a candidate registry. Results. Ten living kidney donor programs evaluated 2107 consecutive kidney donor candidates; 2099 of 2107 (99.6%) completed evaluations, 1578 of 2099 (75.2%) had a decision, and 790 of 1578 (50.1%) were approved to donate as of March 12, 2020. By logistic regression, candidates most likely to be approved were married or had attended college or technical school; those least likely to be approved had ≥1 of the following characteristics: Black race, history of cigarette smoking, and higher blood pressure, higher triglycerides, or higher urine albumin-to-creatinine ratios. Reasons for 617 candidates not being approved included medical issues other than chronic kidney disease risk (25.3%), chronic kidney disease risk (18.5%), candidate withdrawal (15.2%), recipient reason (13.6%), anatomical risk to the recipient (10.3%), noneconomic psychosocial (10.3%), economic (0.5%), and other reasons (6.4%). Conclusions. These results suggest that a comprehensive living donor registry is both feasible and necessary to assess long-term outcomes that may inform decision making for future living donor candidates. There may be socioeconomic barriers to donation that require more granular identification so that active measures can address inequities. Some candidates who did not donate may be suitable controls for discerning the appropriateness of acceptance decisions and the long-term outcomes attributable to donation. We anticipate that these issues will be better identified with modifications to the data collection and expansion of the registry to all centers over the next several years.
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16
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Husain SA, King KL, Sanichar N, Crew RJ, Schold JD, Mohan S. Association Between Donor-Recipient Biological Relationship and Allograft Outcomes After Living Donor Kidney Transplant. JAMA Netw Open 2021; 4:e215718. [PMID: 33847748 PMCID: PMC8044734 DOI: 10.1001/jamanetworkopen.2021.5718] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
IMPORTANCE The proportion of living donor kidney transplants from donors unrelated to their recipients is increasing in the US. OBJECTIVE To examine the association between donor-recipient biological relationship and allograft survival after living donor kidney transplant. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used Organ Procurement and Transplantation Network data on US adult living donor kidney transplants (n = 86 154) performed from January 1, 2000, to December 31, 2014, excluding cases in which recipients previously received a kidney transplant (n = 10 342) or key data were missing (n = 2832). Last follow-up was March 20, 2020. EXPOSURES Donor-recipient biological relationship. MAIN OUTCOMES AND MEASURES The primary outcome was death-censored allograft failure. Univariate and multivariable time-to-event analyses were performed for death-censored allograft failure for the overall cohort, then separately for recipients with and without primary diagnoses of cystic kidney disease and for transplants from African American and non-African American donors. RESULTS Among the 72 980 transplant donor and recipients included in the study (median donor age, 41 years; interquartile range [IQR], 32-50 years; 43 990 [60%] female; 50 014 [69%] White), 43 174 (59%) donors and recipients were biologically related and 29 806 (41%) were unrelated. Donors related to their recipients were younger (median [IQR] age, 39 [31-48] vs 44 [35-52] years) and less likely to be female (24 848 [58%] vs 19 142 [64%]) or White (26 933 [62%] vs 23 081 [77%]). Recipients related to their donors were younger (median [IQR] age, 48 [34-58] vs 50 [40-58] years), more likely to be female (18 035 [42%] vs 10 530 [35%]), and less likely to have cystic kidney disease (2530 [6%] vs 4600 [15%]). Related pairs had fewer HLA mismatches overall (median [IQR], 3 [2-3] vs 5 [4-5]). After adjustment for HLA mismatches, donor and recipient characteristics, and transplant era, donor-recipient biological relationship was associated with higher death-censored allograft failure (hazard ratio, 1.05; 95% CI, 1.01-1.10; P = .03). When stratified by primary disease, this association persisted only for recipients without cystic kidney disease. When stratified by donor race, this association persisted only for transplants from African American donors. CONCLUSIONS AND RELEVANCE In this cohort study, living donor kidney transplants from donors biologically related to their recipients had higher rates of allograft failure than transplants from donors unrelated to their recipients after HLA matching was accounted for. Further study is needed to determine which genetic or socioenvironmental factors are associated with this finding.
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Affiliation(s)
- S. Ali Husain
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York
| | - Kristen L. King
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York
| | - Navin Sanichar
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York
| | - R. John Crew
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York
| | - Jesse D. Schold
- Center for Populations Health Research, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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17
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Berrigan M, Austrie J, Fleishman A, Tercyak KP, Pollak MR, Pavlakis M, Rohan V, Baliga PK, Kayler LK, Feeley TH, Rodrigue JR. Opinions of African American adults about the use of apolipoprotein L1 (ApoL1) genetic testing in living kidney donation and transplantation. Am J Transplant 2021; 21:1197-1205. [PMID: 32659871 PMCID: PMC7854990 DOI: 10.1111/ajt.16206] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/23/2020] [Accepted: 07/07/2020] [Indexed: 02/06/2023]
Abstract
Apolipoprotein L1 (ApoL1) predictive genetic testing for kidney disease, and its emerging role in transplantation, remains controversial as it may exacerbate underlying disparities among African Americans (AAs) at increased risk. We conducted an online simulation among AAs (N = 585) about interest in ApoL1 testing and its cofactors, under 2 scenarios: as a potential living donor (PLD), and as a patient awaiting transplantation. Most respondents (61%) expressed high interest in genetic testing as a PLD: age ≥35 years (adjusted odds ratio [aOR], 1.75; 95% confidence interval [CI], 1.18, 2.60, P = .01), AA identity (aOR, 1.67; 95% CI, 1.02, 2.72, P = .04), perceived kidney disease risk following donation (aOR, 1.68; 95% CI, 1.03, 2.73, P = .03), interest in genetics (aOR, 2.89; 95% CI, 1.95, 4.29, P = .001), and genetics self-efficacy (aOR, 2.38; 95% CI, 1.54, 3.67, P = .001) were positively associated with ApoL1 test interest. If awaiting transplantation, most (89%) believed that ApoL1 testing should be done on AA deceased donors, and older age (aOR, 1.85; 95% CI, 1.03, 3.32, P = .04) and greater interest in genetics (aOR, 2.61; 95% CI, 1.41, 4.81, P = .002) were associated with interest in testing deceased donors. Findings highlight strong support for ApoL1 testing in AAs and the need to examine such opinions among PLDs and transplant patients to enhance patient education efforts.
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Affiliation(s)
- Margaret Berrigan
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Jasmine Austrie
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Aaron Fleishman
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Kenneth P Tercyak
- Departments of Oncology and Pediatrics, Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Martin R Pollak
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Martha Pavlakis
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Vinayak Rohan
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Prabhakar K Baliga
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Liise K Kayler
- Department of Surgery, University at Buffalo (SUNY) Jacobs School of Medicine & Biomedical Sciences and Erie County Medical Center, Buffalo, New York, USA
| | - Thomas H Feeley
- Department of Communication, University at Buffalo (SUNY), Buffalo, New York, USA
| | - James R Rodrigue
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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18
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Gill JS, Brar S. Surveys are sometimes most notable for what they do not tell us. Am J Transplant 2020; 20:3279-3280. [PMID: 32506602 DOI: 10.1111/ajt.16115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 05/26/2020] [Accepted: 05/26/2020] [Indexed: 01/25/2023]
Affiliation(s)
- John S Gill
- Department of Medicine, Division of Nephrology, University of British Columbia, Vancouver, Canada.,Center for Health Evaluation and Outcomes Sciences, Vancouver, Canada
| | - Sandeep Brar
- Department of Medicine, Division of Nephrology, University of British Columbia, Vancouver, Canada.,Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
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19
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Abstract
PURPOSE OF REVIEW To summarize the current state of evidence regarding the role of apolipoprotein L1 (APOL1) genotyping in evaluating donors for kidney transplantation. RECENT FINDINGS African ancestry is associated with an increased risk of kidney failure following living donation. Moreover, kidney transplants from African ancestry deceased donors have an increased risk of graft failure. Preliminary evidence suggests that APOL1 genotype may mediate at least a portion of this racial variation, with high-risk APOL1 genotypes defined by presence of two renal risk variants (RRVs). A pilot study 136 African ancestry living donors found that those with APOL1 high-risk genotypes had lower baseline kidney function and faster rates of kidney function decline after donation. To date, three retrospective studies identified a two-to-three times greater risk of allograft failure associated with kidneys from donors with high-risk APOL1 genotype. Active research initiatives seek to address unanswered questions, including reproducibility in large national samples, the role of 'second hits' injuries, and impact of recipient genotype, with a goal to build consensus on applications for policy and practice. SUMMARY As evidence evolves, APOL1 genotyping may have applications for organ quality scoring in deceased donor kidney allocation, and for the evaluation and selection of living donor candidates.
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Affiliation(s)
- Krista L Lentine
- Saint Louis University Center for Abdominal Transplantation, St. Louis, Missouri
| | - Roslyn B Mannon
- Division of Nephrology, Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
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20
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Using race in the estimation of glomerular filtration rates: time for a reversal? Curr Opin Nephrol Hypertens 2020; 29:227-231. [PMID: 31895163 DOI: 10.1097/mnh.0000000000000587] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Bedside estimates of renal function are essential for clinical practice in the modern era and have largely relied on serum creatinine concentrations despite the known drawbacks associated with this choice of biomarker, including the fact that creatinine clearance overestimates the glomerular filtration rate. RECENT FINDINGS Initial estimates relied primarily on equations that incorporated factors known to influence creatinine concentrations such as age, sex and anthropometric measures. More recent estimates of glomerular filtration rate have replaced the anthropometric measures with the social construct of race, suggesting that glomerular filtration rates for black individuals are higher at the same concentration of creatinine. This approach has led to large variations in the estimated differences in glomerular filtration rate between black and nonblack individuals in the United States that have not been reproducible, resulting in a plethora of population-specific formulae across the country. SUMMARY The introduction of race in estimated glomerular filtration rate equations may have potential unintended negative consequences for the very population with the greatest burden of kidney disease. These potential disadvantages underscore the need to perhaps return to the replacement of race with more objective anthropometric measures without the loss of precision.
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21
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Freedman BI, Moxey-Mims MM, Alexander AA, Astor BC, Birdwell KA, Bowden DW, Bowen G, Bromberg J, Craven TE, Dadhania DM, Divers J, Doshi MD, Eidbo E, Fornoni A, Gautreaux MD, Gbadegesin RA, Gee PO, Guerra G, Hsu CY, Iltis AS, Jefferson N, Julian BA, Klassen DK, Koty PP, Langefeld CD, Lentine KL, Ma L, Mannon RB, Menon MC, Mohan S, Moore JB, Murphy B, Newell KA, Odim J, Ortigosa-Goggins M, Palmer ND, Park M, Parsa A, Pastan SO, Poggio ED, Rajapakse N, Reeves-Daniel AM, Rosas SE, Russell LP, Sawinski D, Smith SC, Spainhour M, Stratta RJ, Weir MR, Reboussin DM, Kimmel PL, Brennan DC. APOL1 Long-term Kidney Transplantation Outcomes Network (APOLLO): Design and Rationale. Kidney Int Rep 2020; 5:278-288. [PMID: 32154449 PMCID: PMC7056919 DOI: 10.1016/j.ekir.2019.11.022] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 11/22/2019] [Accepted: 11/25/2019] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Much of the higher risk for end-stage kidney disease (ESKD) in African American individuals relates to ancestry-specific variation in the apolipoprotein L1 gene (APOL1). Relative to kidneys from European American deceased-donors, kidneys from African American deceased-donors have shorter allograft survival and African American living-kidney donors more often develop ESKD. The National Institutes of Health (NIH)-sponsored APOL1 Long-term Kidney Transplantation Outcomes Network (APOLLO) is prospectively assessing kidney allograft survival from donors with recent African ancestry based on donor and recipient APOL1 genotypes. METHODS APOLLO will evaluate outcomes from 2614 deceased kidney donor-recipient pairs, as well as additional living-kidney donor-recipient pairs and unpaired deceased-donor kidneys. RESULTS The United Network for Organ Sharing (UNOS), Association of Organ Procurement Organizations, American Society of Transplantation, American Society for Histocompatibility and Immunogenetics, and nearly all U.S. kidney transplant programs, organ procurement organizations (OPOs), and histocompatibility laboratories are participating in this observational study. APOLLO employs a central institutional review board (cIRB) and maintains voluntary partnerships with OPOs and histocompatibility laboratories. A Community Advisory Council composed of African American individuals with a personal or family history of kidney disease has advised the NIH Project Office and Steering Committee since inception. UNOS is providing data for outcome analyses. CONCLUSION This article describes unique aspects of the protocol, design, and performance of APOLLO. Results will guide use of APOL1 genotypic data to improve the assessment of quality in deceased-donor kidneys and could increase numbers of transplanted kidneys, reduce rates of discard, and improve the safety of living-kidney donation.
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Affiliation(s)
- Barry I. Freedman
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Marva M. Moxey-Mims
- Division of Nephrology, Children's National Health System, Washington, DC, USA
| | - Amir A. Alexander
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Brad C. Astor
- Department of Medicine, Division of Nephrology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Kelly A. Birdwell
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University, Nashville, Tennessee, USA
| | - Donald W. Bowden
- Department of Biochemistry, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | | | - Jonathan Bromberg
- Department of Surgery, Division of Transplantation, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Microbiology and Immunology, Division of Transplantation, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Timothy E. Craven
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Darshana M. Dadhania
- Division of Nephrology, Weill Cornell Medicine, New York, New York, USA
- Department of Transplantation Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Jasmin Divers
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Mona D. Doshi
- Division of Nephrology, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Elling Eidbo
- Association of Organ Procurement Organizations, Vienna, Virginia, USA
| | - Alessia Fornoni
- Katz Family Division of Nephrology and Hypertension, Peggy and Harold Katz Drug Discovery Center, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Michael D. Gautreaux
- Human Leukocyte Antigen/Immunogenetics and Immunodiagnostics Laboratories, Department of Pathology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Rasheed A. Gbadegesin
- Department of Pediatrics, Division of Nephrology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Patrick O. Gee
- APOLLO Community Advisory Council, Cleveland Clinic, Cleveland, Ohio, USA
| | - Giselle Guerra
- Katz Family Division of Nephrology and Hypertension, Peggy and Harold Katz Drug Discovery Center, University of Miami Miller School of Medicine, Miami, Florida, USA
- Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Chi-yuan Hsu
- Department of Medicine, Division of Nephrology, University of California, San Francisco, San Francisco, California, USA
| | - Ana S. Iltis
- Center for Bioethics, Health and Society, Department of Philosophy, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Nichole Jefferson
- APOLLO Steering Committee, APOLLO Community Advisory Council, Dallas, Texas, USA
| | - Bruce A. Julian
- Department of Medicine, Division of Nephrology, University of Alabama School of Medicine in Birmingham, Birmingham, Alabama, USA
| | - David K. Klassen
- United Network for Organ Sharing, Office of the Chief Medical Officer, Richmond, Virginia, USA
| | - Patrick P. Koty
- Department of Pathology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Carl D. Langefeld
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Krista L. Lentine
- Department of Medicine, Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - Lijun Ma
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Roslyn B. Mannon
- Department of Medicine, Division of Nephrology, University of Alabama School of Medicine in Birmingham, Birmingham, Alabama, USA
| | - Madhav C. Menon
- Department of Nephrology, Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Recanati-Miller Transplant Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - J. Brian Moore
- Institutional Review Board, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Barbara Murphy
- Department of Nephrology, Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Recanati-Miller Transplant Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kenneth A. Newell
- Department of Surgery, Division of Transplantation, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jonah Odim
- Transplantation Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Mariella Ortigosa-Goggins
- Katz Family Division of Nephrology and Hypertension, Peggy and Harold Katz Drug Discovery Center, University of Miami Miller School of Medicine, Miami, Florida, USA
- Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Nicholette D. Palmer
- Department of Biochemistry, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Meyeon Park
- Department of Medicine, Division of Nephrology, University of California, San Francisco, San Francisco, California, USA
| | - Afshin Parsa
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, USA
| | - Stephen O. Pastan
- Department of Medicine, Renal Division, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Emilio D. Poggio
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nishadi Rajapakse
- National Institutes of Health, National Institute on Minority Health and Health Disparities, Division of Scientific Programs, Bethesda, Maryland, USA
| | - Amber M. Reeves-Daniel
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Sylvia E. Rosas
- Kidney and Hypertension Unit, Joslin Diabetes Center and Harvard Medical School, Boston, Massachusetts, USA
- Division of Nephrology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Laurie P. Russell
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Deirdre Sawinski
- Renal Electrolyte and Hypertension Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - S. Carrie Smith
- Department of Biochemistry, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Mitzie Spainhour
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Robert J. Stratta
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Matthew R. Weir
- Department of Medicine, Division of Nephrology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - David M. Reboussin
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Paul L. Kimmel
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, USA
| | - Daniel C. Brennan
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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22
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Kopp JB, Winkler CA. Genetic Testing for APOL1 Genetic Variants in Clinical Practice: Finally Starting to Arrive. Clin J Am Soc Nephrol 2020; 15:126-128. [PMID: 31740572 PMCID: PMC6946079 DOI: 10.2215/cjn.01810219] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Jeffrey B. Kopp
- Kidney Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases and Basic Research Laboratory, National Cancer Institute, National Institutes of Health, Bethesda, Maryland; and
| | - Cheryl A. Winkler
- Basic Research Program Frederick National Laboratories for Cancer Research, Frederick, Maryland
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23
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McIntosh T, Mohan S, Sawinski D, Iltis A, DuBois JM. Variation of ApoL1 Testing Practices for Living Kidney Donors. Prog Transplant 2019; 30:22-28. [PMID: 31838940 DOI: 10.1177/1526924819892917] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Tests exist for ApoL1 genetic variants to determine whether a potential donor's kidneys are at increased risk of kidney failure. Variants of the ApoL1 gene associated with increased risk are primarily found in people with West African ancestry. Given uncertainty about clinical implications of ApoL1 test results for living kidney donors and recipients and the lack of uniform guidelines for ApoL1 testing, transplant centers across the United States vary in ApoL1 testing practices. RESEARCH QUESTIONS (1) What approach do transplant centers take to determine whether prospective donors are of West African ancestry? (2)How do transplant centers engage potential donors during the ApoL1 testing process? (3) What do transplant centers identify as concerns and barriers to ApoL1 testing? and (4) What actions do transplant centers take when a potential donor has 2 ApoL1 risk variants? DESIGN We explored the current practices of transplant centers by surveying nephrologists and transplant surgeons at transplant centers evaluating the majority of black living donors in the United States. RESULTS About half of these transplant centers offered ApoL1 testing. Of those who offered ApoL1 testing, only half involved the donor in decision-making about donation when the donor has 2 risk variants. DISCUSSION Unaddressed differences in the priorities of transplant centers and black living donors may stigmatize black donors and undermine trust in the health-care and organ donation systems. Variation in transplant center testing practices points to the critical need for further research and community engagement to inform the development of guidelines for ApoL1 testing.
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Affiliation(s)
- Tristan McIntosh
- Division of General Medical Sciences, Department of Medicine, Washington University School of Medicine, St Louis, MO, USA
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine Columbia University Vagelos College of Physicians & Surgeons, New York, NY, USA.,Department of Epidemiology, Columbia University, Mailman School of Public Health, New York, NY, USA.,Columbia University Renal Epidemiology (CURE) Group, New York, NY, USA
| | - Deirdre Sawinski
- Renal, Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ana Iltis
- Department of Philosophy, Wake Forest University, Winston Salem, NC, USA.,Center for Bioethics Health and Society, Wake Forest University, Winston Salem, NC, USA
| | - James M DuBois
- Division of General Medical Sciences, Department of Medicine, Washington University School of Medicine, St Louis, MO, USA
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24
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Neugut YD, Mohan S, Gharavi AG, Kiryluk K. Cases in Precision Medicine: APOL1 and Genetic Testing in the Evaluation of Chronic Kidney Disease and Potential Transplant. Ann Intern Med 2019; 171:659-664. [PMID: 31590185 PMCID: PMC7441647 DOI: 10.7326/m19-1389] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
This article discusses potential indications for genetic testing in an African American patient with chronic kidney disease who is being evaluated for a kidney transplant. Two known risk variants in the APOL1 (apolipoprotein L1) gene predispose to kidney disease and are found almost exclusively in persons of African ancestry. APOL1 risk variants are considered, including whether clinicians should incorporate genetic testing in the screening process for living kidney donors. In addition to APOL1 testing, the role of diagnostic exome sequencing in evaluating potential transplant recipients and donors with a positive family history of kidney disease is discussed.
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Affiliation(s)
- Y Dana Neugut
- Columbia University, New York, New York (Y.D.N., S.M., A.G.G., K.K.)
| | - Sumit Mohan
- Columbia University, New York, New York (Y.D.N., S.M., A.G.G., K.K.)
| | - Ali G Gharavi
- Columbia University, New York, New York (Y.D.N., S.M., A.G.G., K.K.)
| | - Krzysztof Kiryluk
- Columbia University, New York, New York (Y.D.N., S.M., A.G.G., K.K.)
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25
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Affiliation(s)
- Jordan Nestor
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York, USA
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, New York, USA
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA
- The Columbia University Renal Epidemiology (CURE) Group, New York, New York, USA
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