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Patel S, Alfafara C, Kraus MB, Buckner-Petty S, Bonner T, Youssef MR, Poterack KA, Mour G, Mathur AK, Milam AJ. Individual- and Community-Level Socioeconomic Status and Deceased Donor Renal Transplant Outcomes. J Racial Ethn Health Disparities 2023:10.1007/s40615-023-01851-8. [PMID: 37962790 DOI: 10.1007/s40615-023-01851-8] [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: 08/25/2023] [Revised: 10/21/2023] [Accepted: 10/24/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND This study examined the relationship between socioeconomic status (SES), race, and ethnicity and clinical outcomes following deceased donor kidney transplant (DDKT) at a high-volume transplant center. METHODS This retrospective cohort study used regression models and survival analyses to examine the relationship between individual- and community-level SES, race, and ethnicity and DDKT outcomes (i.e., delayed graft function, graft failure, mortality) adjusting for potential confounders. RESULTS The analytic sample included 3366 patients; 40.7% (n = 1370) were female, the mean age was 54.7 (SD = 13.3) years, 49.3% were non-Hispanic White, and the median follow-up time was 39.5 months (IQR = 24.2-68.1). Patients living in the most disadvantaged communities (using the US Census data) had a higher likelihood of delayed graft function (adjusted relative risk [RR] = 1.12, p = 0.042) and a higher hazard of mortality (adjusted hazard ratio [HR] = 1.32, p = 0.025) compared to patients living in the least disadvantaged communities. Patients without a high school diploma had a higher risk of delayed graft function compared to patients with an associate degree or more (RR = 1.37, p < 0.001). Patients with public insurance coverage had a higher risk of delayed graft function (RR = 1.24, p < 0.001) and a higher hazard of mortality (HR = 1.37, p < 0.001) and graft failure (HR = 1.71, p < 0.001) compared to patients without public insurance. There were no differences in graft failure or mortality by race and ethnicity. CONCLUSIONS SES was not consistently associated with outcomes following DDKT; however, many of the predictors were associated with delayed graft function. With a large and diverse sample size, these findings further the heterogeneity of the present renal transplant research suggesting the need for further investigation to guide implementation of innovative strategies and interventions.
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Affiliation(s)
- Shyam Patel
- Mayo Clinic Alix School of Medicine, Scottsdale, AZ, 85259, USA
| | - Chelsea Alfafara
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Molly B Kraus
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Skye Buckner-Petty
- Department of Clinical Trials and Biostatistics, Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Timethia Bonner
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Mohanad R Youssef
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Karl A Poterack
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Girish Mour
- Division of Nephrology, Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Amit K Mathur
- Division of Transplant Surgery, Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Adam J Milam
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ, 85054, USA.
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2
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Ivanics T, Wallace D, Abreu P, Claasen MPAW, Callaghan C, Cowling T, Walker K, Heaton N, Mehta N, Sapisochin G, van der Meulen J. Survival After Liver Transplantation: An International Comparison Between the United States and the United Kingdom in the Years 2008-2016. Transplantation 2022; 106:1390-1400. [PMID: 34753895 DOI: 10.1097/tp.0000000000003978] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Compared with the United States, risk-adjusted mortality in the United Kingdom has historically been worse in the first 90 d following liver transplantation (LT) and better thereafter. In the last decade, there has been considerable change in the practice of LT internationally, but no contemporary large-scale international comparison of posttransplant outcomes has been conducted. This study aimed to determine disease-specific short- and long-term mortality of LT recipients in the United States and the United Kingdom. METHODS This retrospective international multicenter cohort study analyzed adult (≥18 y) first-time LT recipients between January 2, 2008, and December 31, 2016, using the Organ Procurement and Transplantation Network/United Network for Organ Sharing and the UK Transplant Registry databases. Time-dependent Cox regression estimated hazard ratios (HRs) comparing disease-specific risk-adjusted mortality in the first 90 d post-LT, between 90 d and 1 y, and between 1 and 5 y. RESULTS Forty-two thousand eight hundred seventy-four US and 4950 UK LT recipients were included. The main LT indications in the United States and the United Kingdom were hepatocellular carcinoma (25.4% and 24.9%, respectively) and alcohol-related liver disease (20.3% and 27.1%, respectively). There were no differences in mortality during the first 90 d post-LT (reference: United States; HR, 0.96; 95% confidence interval [CI], 0.82-1.12). However, between 90 d and 1 y (HR, 0.71; 95% CI, 0.59-0.85) and 1 and 5 y (HR, 0.71; 95% CI, 0.63-0.81]) the United Kingdom had lower mortality. The mortality differences between 1 and 5 y were most marked in hepatocellular carcinoma (HR, 0.71; 95% CI, 0.58-0.88) and alcohol-related liver disease patients (HR, 0.64; 95% CI, 0.45-0.89). CONCLUSIONS Risk-adjusted mortality in the United States and the United Kingdom was similar in the first 90 d post-LT but better in the United Kingdom thereafter. International comparisons of LT may highlight differences in healthcare delivery and help benchmarking by identifying modifiable factors that can facilitate improved global outcomes in LT.
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Affiliation(s)
- Tommy Ivanics
- Division of General Surgery, Multi-organ Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada
- Department of Surgery, Henry Ford Hospital, Detroit, MI
| | - David Wallace
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Department of Nephrology and Transplantation, Guys and St Thomas' National Health Service Foundation Trust, London, United Kingdom
| | - Phillipe Abreu
- Division of General Surgery, Multi-organ Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Marco P A W Claasen
- Division of General Surgery, Multi-organ Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada
- Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Chris Callaghan
- Department of Nephrology and Transplantation, Guys and St Thomas' National Health Service Foundation Trust, London, United Kingdom
| | - Thomas Cowling
- Institute of Liver Studies, King's College Hospital National Health Service Foundation Trust, London, United Kingdom
| | - Kate Walker
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Nigel Heaton
- Institute of Liver Studies, King's College Hospital National Health Service Foundation Trust, London, United Kingdom
| | - Neil Mehta
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Gonzalo Sapisochin
- Division of General Surgery, Multi-organ Transplant Program, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Jan van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
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3
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Ford JA, Tumin D, Beng H, Gomez Mendez LM. The Relationship Between Change in Employment Status, Insurance Coverage, and Graft Failure or Death After Kidney Transplant. Prog Transplant 2022; 32:203-211. [PMID: 35686356 DOI: 10.1177/15269248221107046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction: Early change of insurance coverage after kidney transplantation may be associated with worse graft outcomes. We examine how return to employment moderates the hazard of graft failure associated with exit from Medicare within 36 months after transplantation. Design: Patients undergoing kidney transplantation covered by Medicare between January 2005 and December 2016 were identified in the United Network for Organ Sharing (UNOS) database. A composite outcome of graft failure or death was analyzed across four groups: (1) no change in coverage within the first 3 years post-transplant, and no return to work (2) no change in coverage, return to work (3) change in coverage, no return to work (4) change in coverage, return to work. Results: The sample included 46 120 patients; 28% changed insurance coverage from Medicare posttransplant. Among patients who returned to work (36%), change in coverage from Medicare to other insurance was associated with lower hazard of death or graft failure (hazard ratio: 0.93; 95% confidence interval: 0.87, 0.99; P = 0.030). Conclusions: Exit from Medicare was associated with patient and graft survival greater than 3 years after transplant, depending on return to work. Among patients returning to work, changes in insurance from Medicare to private coverage were associated with favorable outcomes.
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Affiliation(s)
- Jacob A Ford
- Department of Pediatrics, 12278Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Dmitry Tumin
- Department of Pediatrics, 12278Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Hostensia Beng
- Department of Pediatrics, 12278Brody School of Medicine at East Carolina University, Greenville, NC, USA
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4
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Organization of Post-Transplant Care and the 5-Year Outcomes of Kidney Transplantation. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19042010. [PMID: 35206198 PMCID: PMC8872049 DOI: 10.3390/ijerph19042010] [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: 01/05/2022] [Revised: 02/01/2022] [Accepted: 02/07/2022] [Indexed: 12/10/2022]
Abstract
The outcomes of kidney transplantation depend on numerous factors and vary between transplant centers. The aim of this study is to assess the relationship between selected organizational factors, comorbidities, and patient and graft survival. This is a retrospective analysis of 438 renal transplant recipients (RTR) followed for 5 years. Patient and graft survival were evaluated in relation to hospitalization length, distance from the patient's residence to the transplant center, the frequency of outpatient transplant visits, and the number and type of comorbidities. Five-year patient and graft survival rates were 93% and 90%, respectively. We found significant associations of patient survival with the prevalence of pre-transplant diabetes, cardiovascular diseases, malignancies, the number of comorbidities, and the first post-transplant hospitalization length. The incidence of infections, cardiovascular diseases, and transplanted kidney diseases was 60%, 40%, and 33%, respectively. As many as 41% of RTR had unknown etiology of primary kidney disease. In conclusion, the organization of post-transplant care needs to be adapted to the multi-morbidity of contemporary RTR and include multi-specialist care, especially in the context of current problems related to the COVID-19pandemic. The high proportion of patients with undetermined etiology of their primary renal disease carry the risk for additional complications during their long-term follow-up.
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5
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Kute V, Gupta V, Patel H, Banerjee S, Engineer D, Meshram H, Navadia V, Patel A. Role of telemedicine in kidney transplant recipient in COVID-19 era. INDIAN JOURNAL OF TRANSPLANTATION 2022. [DOI: 10.4103/ijot.ijot_154_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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6
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Levan ML, Reich DJ, Segev D. After 20 Years of Advocacy, Comprehensive Immunosuppressive Drug Coverage for Kidney Transplant Patients Finally Become Law. Transplantation 2022; 106:9-11. [PMID: 34342961 PMCID: PMC8678179 DOI: 10.1097/tp.0000000000003899] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Macey L. Levan
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Department of Acute and Chronic Care, Johns Hopkins School of Nursing, Baltimore, MD, USA
| | - David J. Reich
- Department of Surgery, Drexel University College of Medicine, Philadelphia, PA, USA
- Tower Health Transplant Institute, West Reading, PA, USA
| | - Dorry Segev
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Department of Acute and Chronic Care, Johns Hopkins School of Nursing, Baltimore, MD, USA
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7
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Gill JS, Formica RN, Murphy B. Passage of the Comprehensive Immunosuppressive Drug Coverage for Kidney Transplant Patients Act-a Chance to Celebrate and Reflect. J Am Soc Nephrol 2021; 32:774-776. [PMID: 33653687 PMCID: PMC8017546 DOI: 10.1681/asn.2020121811] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- John S. Gill
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Richard N. Formica
- Department of Medicine, Section of Nephrology and Department of Surgery, Section of Organ Transplantation and Immunology, Yale University School of Medicine, New Haven, Connecticut
| | - Barbara Murphy
- Icahn School of Medicine at Mount Sinai New York, New York
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8
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Denhaerynck K, Goldfarb-Rumyantzev AS, Sandhu G, Beckmann S, Huynh-Do U, Binet I, De Geest S. Pre-transplant Social Adaptability Index and clinical outcomes in renal transplantation: The Swiss Transplant Cohort study. Clin Transplant 2021; 35:e14218. [PMID: 33406303 DOI: 10.1111/ctr.14218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 12/25/2020] [Accepted: 12/29/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND The impact of pre-transplant social determinants of health on post-transplant outcomes remains understudied. In the United States, poor clinical outcomes are associated with underprivileged status, as assessed by the Social Adaptability Index (SAI), a composite score of education, employment status, marital status, household income, and substance abuse. Using data from the Swiss Transplant Cohort Study (STCS), we determined the SAI's predictive value regarding two post-transplant outcomes: all-cause mortality and return to dialysis. METHODS Between 2012 and 2018, we included adult renal transplant patients (aged ≥ 18 years) with pre-transplant assessment SAI scores, calculated from a STCS Psychosocial Questionnaire. Time to all-cause mortality and return to dialysis were predicted using Cox regression. RESULTS Of 1238 included patients (mean age: 53.8 ± 13.2 years; 37.9% female; median follow-up time: 4.4 years [IQR: 2.7]), 93 (7.5%) died and 57 (4.6%) returned to dialysis. The SAI's hazard ratio was 0.94 (95%CI: 0.88-1.01; p = .09) for mortality and 0.93 (95%CI: 0.85-1.02; p = .15) for return to dialysis. CONCLUSIONS In contrast to most published studies on social deprivation, analysis of this Swiss sample detected no significant association between SAI score and mortality or return to dialysis.
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Affiliation(s)
- Kris Denhaerynck
- Institute of Nursing Science, Department of Public Health, University of Basel, Basel, Switzerland
| | | | - Gurprataap Sandhu
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Sonja Beckmann
- Institute of Nursing Science, Department of Public Health, University of Basel, Basel, Switzerland.,Center of Clinical Nursing Science, University Hospital Zurich, Zurich, Switzerland
| | - Uyen Huynh-Do
- Department of Nephrology and Hypertension, University Hospital Inselspital, Bern, Switzerland
| | - Isabelle Binet
- Nephrology and Transplantation Medicine, Cantonal Hospital, St Gallen, Switzerland
| | - Sabina De Geest
- Institute of Nursing Science, Department of Public Health, University of Basel, Basel, Switzerland.,Academic Center of Nursing and Midwifery, Department of Public Health and Primary Care, KU Leuven, Belgium
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9
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HOUSES Index as an Innovative Socioeconomic Measure Predicts Graft Failure Among Kidney Transplant Recipients. Transplantation 2021; 104:2383-2392. [PMID: 31985729 DOI: 10.1097/tp.0000000000003131] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Despite extensive evaluation processes to determine candidacy for kidney transplantation, variability in graft failure exists. The role of patient socioeconomic status (SES) in transplantation outcomes is poorly understood because of limitations of conventional SES measures. METHODS This population-based retrospective cohort study assessed whether a validated objective and individual-level housing-based SES index (HOUSES) would serve as a predictive tool for graft failure in patients (n = 181) who received a kidney transplant in Olmsted County, MN (January 1, 1998 to December 8, 2016). Associations were assessed between HOUSES (quartiles: Q1 [lowest] to Q4 [highest]) and graft failure until last follow-up date (December 31, 2016) using Cox proportional hazards. The mean age (SD) was 46.1 (17.2) years, 109 (60.2%) were male, 113 (62.4%) received a living kidney donor transplant, and 40 (22.1%) had a graft failure event. RESULTS Compared with Q1, patients with higher HOUSES (Q2-Q4) had significantly lower graft failure rates (adjusted hazard ratio, 0.47; 95% confidence interval, 0.24-0.92; P < 0.029), controlling for age, sex, race, previous kidney transplantation, and donor type. CONCLUSIONS Although criteria for kidney transplant recipients are selective, patients with higher HOUSES had lower graft failure rates. Thus, HOUSES may enable transplantation programs to identify a target group for improving kidney transplantation outcomes.
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10
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Sanders-Pinheiro H, Colugnati FAB, Denhaerynck K, Marsicano EO, Medina JOP, De Geest S. Multilevel Correlates of Immunosuppressive Nonadherence in Kidney Transplant Patients: The Multicenter ADHERE BRAZIL Study. Transplantation 2021; 105:255-266. [PMID: 32150041 DOI: 10.1097/tp.0000000000003214] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Immunosuppressive nonadherence is a risk factor for worse outcomes after kidney transplantation (KT). Brazil, having the world's largest public, fully covered transplantation system and the second-highest KT volume worldwide, provides a unique setting for studying multilevel correlates of nonadherence (patient, healthcare provider, transplant center, and healthcare system levels) independent of patients' financial burden. METHODS By applying a multistage sampling approach, we included 1105 patients from 20 KT centers. Nonadherence to immunosuppressives (implementation phase) was defined as any deviation in taking or timing adherence and dose reduction assessed by the Basel Assessment of Adherence to Immunosuppressive Medications Scale. Based on Bronfenbrenner's ecological model, we assessed multilevel factors using established instruments and measures specifically developed for this study and analyzed their independent contribution to nonadherence by performing sequential logistic regression analysis. RESULTS The nonadherence prevalence rate was 39.7%. The following factors were independently associated with nonadherence: Patient level-having a stable partner (odds ratio [OR]: 0.75; confidence interval [CI]: 0.58-0.97), nonadherence to appointments (OR: 2.98; CI: 2.03-4.39), and nonadherence to physical activity recommendations (OR: 1.84; CI: 1.38-2.46); and transplant center level-satisfaction with the waiting room structure (OR: 0.54; CI: 0.42-0.71), consultation >30 minutes (OR: 1.60; CI: 1.19-2.14), adequacy of the consultation frequency (OR: 0.62; CI: 0.43-0.90), and centers with >500 beds (OR: 0.58; CI: 0.46-0.73). CONCLUSIONS As the first multicenter study assessing multilevel correlates of nonadherence in KT, our findings point to the need for multilevel interventions beyond the patient level, targeting transplant center practice patterns as an approach to tackle nonadherence.
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Affiliation(s)
- Helady Sanders-Pinheiro
- Renal Transplantation Unit, University Hospital, Federal University of Juiz de Fora, Minas Gerais, Brazil and Núcleo Interdisciplinar de Estudos e Pesquisas em Nefrologia (NIEPEN), Juiz de Fora, Minas Gerais, Brazil
| | - Fernando A B Colugnati
- Renal Transplantation Unit, University Hospital, Federal University of Juiz de Fora, Minas Gerais, Brazil and Núcleo Interdisciplinar de Estudos e Pesquisas em Nefrologia (NIEPEN), Juiz de Fora, Minas Gerais, Brazil
| | - Kris Denhaerynck
- Department of Public Health, Institute of Nursing Science, University of Basel, Basel, Switzerland
| | - Elisa O Marsicano
- Renal Transplantation Unit, University Hospital, Federal University of Juiz de Fora, Minas Gerais, Brazil and Núcleo Interdisciplinar de Estudos e Pesquisas em Nefrologia (NIEPEN), Juiz de Fora, Minas Gerais, Brazil
| | - José O P Medina
- Hospital do Rim e Hipertensão, Oswaldo Ramos Foundation, Nephrology Discipline, Federal University of São Paulo, São Paulo, Brazil
| | - Sabina De Geest
- Department of Public Health, Institute of Nursing Science, University of Basel, Basel, Switzerland
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Leuven, Belgium
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11
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Rizzolo K, Cervantes L. Immigration status and end-stage kidney disease: Role of policy and access to care. Semin Dial 2020; 33:513-522. [PMID: 33089565 DOI: 10.1111/sdi.12919] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Immigration status is an important mitigating factor in determining the provision of dialysis and kidney-related care. Immigrants make up the largest uninsured group in the country. For immigrants with end-stage kidney disease (ESKD), dialysis access varies by insurance type and by state, leading to great variability in the availability of kidney care. In some states, undocumented immigrants may only qualify for hemodialysis when critically ill (emergency hemodialysis), which is associated with higher mortality, hospital length of stay, and cost, in addition to an emotional burden on patients, their caregivers, and healthcare professionals. Barriers to effective care for immigrants with ESKD include immigration status, insurance access, and availability of pre-end stage kidney disease care, vascular access, and transplant. Effective strategies for improving dialysis care for immigrants include advocacy at the state and federal level, broadening definitions under Emergency Medicaid, and improving benefits for home therapies and transplantation options.
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Affiliation(s)
- Katherine Rizzolo
- Division of Renal Disease and Hypertension, University of Colorado, Aurora, CO, USA
| | - Lilia Cervantes
- Division of Hospital Medicine and Office of Research, Denver Health, Denver, CO, USA.,Division of General Internal Medicine and Hospital Medicine, University of Colorado, Aurora, CO, USA
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12
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Coca A, Arias-Cabrales C, Valencia AL, Burballa C, Bustamante-Munguira J, Redondo-Pachón D, Acosta-Ochoa I, Crespo M, Bustamante J, Mendiluce A, Pascual J, Pérez-Saéz MJ. Validation of a survival benefit estimator tool in a cohort of European kidney transplant recipients. Sci Rep 2020; 10:17109. [PMID: 33051519 PMCID: PMC7555860 DOI: 10.1038/s41598-020-74295-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 09/21/2020] [Indexed: 12/21/2022] Open
Abstract
Pre-transplant prognostic scores help to optimize donor/recipient allocation and to minimize organ discard rates. Since most of these scores come from the US, direct application in non-US populations is not advisable. The Survival Benefit Estimator (SBE), built upon the Estimated Post-Transplant Survival (EPTS) and the Kidney Donor Profile Index (KDPI), has not been externally validated. We aimed to examine SBE in a cohort of Spanish kidney transplant recipients. We designed a retrospective cohort-based study of deceased-donor kidney transplants carried out in two different Spanish hospitals. Unadjusted and adjusted Cox models were applied for patient survival. Predictive models were compared using Harrell’s C statistics. SBE, EPTS and KDPI were independently associated with patient survival (p ≤ 0.01 in all models). Model discrimination measured with Harrell’s C statistics ranged from 0.57 (KDPI) to 0.69 (SBE) and 0.71 (EPTS). After adjustment, SBE presented similar calibration and discrimination power to that of EPTS. SBE tended to underestimate actual survival, mainly among high EPTS recipients/high KDPI donors. SBE performed acceptably well at discriminating post-transplant survival in a cohort of Spanish deceased-donor kidney transplant recipients, although its use as the main allocation guide, especially for high KDPI donors or high EPTS recipients requires further testing.
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Affiliation(s)
- Armando Coca
- Department of Nephrology, Hospital Clínico Universitario de Valladolid, Avda. Ramón y Cajal SN, 47003, Valladolid, Spain. .,Grupo de Trabajo de Jóvenes Nefrólogos de la Sociedad Española de Nefrología (JovSEN), Madrid, Spain.
| | - Carlos Arias-Cabrales
- Nephrology Department, Hospital del Mar, Barcelona, Spain.,Grupo de Trabajo de Jóvenes Nefrólogos de la Sociedad Española de Nefrología (JovSEN), Madrid, Spain
| | - Ana Lucía Valencia
- Nephrology Department, Hospital Universitario Río Hortega, Valladolid, Spain
| | - Carla Burballa
- Nephrology Department, Hospital del Mar, Barcelona, Spain.,Grupo de Trabajo de Jóvenes Nefrólogos de la Sociedad Española de Nefrología (JovSEN), Madrid, Spain
| | | | - Dolores Redondo-Pachón
- Nephrology Department, Hospital del Mar, Barcelona, Spain.,Grupo de Trabajo de Jóvenes Nefrólogos de la Sociedad Española de Nefrología (JovSEN), Madrid, Spain
| | - Isabel Acosta-Ochoa
- Department of Nephrology, Hospital Clínico Universitario de Valladolid, Avda. Ramón y Cajal SN, 47003, Valladolid, Spain
| | - Marta Crespo
- Nephrology Department, Hospital del Mar, Barcelona, Spain
| | - Jesús Bustamante
- Medicine, Dermatology and Toxicology Department, School of Medicine, Universidad de Valladolid, Valladolid, Spain
| | - Alicia Mendiluce
- Department of Nephrology, Hospital Clínico Universitario de Valladolid, Avda. Ramón y Cajal SN, 47003, Valladolid, Spain
| | - Julio Pascual
- Nephrology Department, Hospital del Mar, Barcelona, Spain
| | - María José Pérez-Saéz
- Nephrology Department, Hospital del Mar, Barcelona, Spain.,Grupo de Trabajo de Jóvenes Nefrólogos de la Sociedad Española de Nefrología (JovSEN), Madrid, Spain
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13
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Wesolowska-Gorniak K, Wojtowicz M, Gierus J, Czarkowska-Paczek B. The correlation of patients' anxiety after a liver or kidney transplantation with functional and self-reported work ability. Medicine (Baltimore) 2020; 99:e20108. [PMID: 32358401 PMCID: PMC7440135 DOI: 10.1097/md.0000000000020108] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Organ transplantation has become the treatment of choice for end-stage organ failure, including renal and liver failure. The benefits of patient employment after transplantation are numerous, but factors determining the ability to work among these patients are not clearly defined. The growing interest in these factors has strong practical implications for organizations creating vocational rehabilitation programs. Given the interconnection between psychological and physical functioning in patients after transplantation, the present study examined the impact of anxiety on vocational rehabilitation and its relationship with functional tests. A total of 100 patients after liver or kidney transplantation underwent functional tests, including the 6-minute walking test and 30-second chair stand test (30"CST), and psychological tests, specifically the Inventory of Physical Activity Objectives, Work Ability Index, and State-Train Anxiety Inventory. Working ability was affected by psychological factors. State and trait anxiety exhibited inverse relationships with subjective readiness to occupational activity (P < .001, r = -.59 and P < .001, r = -.56, respectively). The level of anxiety was negatively related to the results of the 30"CST. State-Train Anxiety Inventory, State Anxiety subscale and State-Train Anxiety Inventory, State-Trait Anxiety subscale vs 30"CST: P < .001, r = -.43 P < .001, r = -.44). Thus, state and trait anxiety influence perceived work ability and partially functional status. These observations may indicate the potential benefits of including psychologists in interdisciplinary teams for physical and especially vocational rehabilitation of patients after liver or kidney transplantation.
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Affiliation(s)
| | - Monika Wojtowicz
- Department of Immunology, Transplantology, and Internal Diseases, Warsaw
| | - Jacek Gierus
- Clinic of Psychiatry, Medical University of Warsaw, Pruszkow, Poland
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Shantier M, Li Y, Ashwin M, Famure O, Singh SK. Use of the Living Kidney Donor Profile Index in the Canadian Kidney Transplant Recipient Population: A Validation Study. Can J Kidney Health Dis 2020; 7:2054358120906976. [PMID: 32128225 PMCID: PMC7036490 DOI: 10.1177/2054358120906976] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 12/01/2019] [Indexed: 12/14/2022] Open
Abstract
Background: The Living Kidney Donor Profile Index (LKDPI) was derived in a cohort of
kidney transplant recipients (KTR) from the United States to predict the
risk of total graft failure. There are important differences in patient
demographics, listing practices, access to transplantation, delivery of
care, and posttransplant mortality in Canada as compared with the United
States, and the generalizability of the LKDPI in the Canadian context is
unknown. Objective: The purpose of this study was to externally validate the LKDPI in a large
contemporary cohort of Canadian KTR. Design: Retrospective cohort validation study. Setting: Toronto General Hospital, University Health Network, Toronto, Ontario,
Canada Patients: A total of 645 adult (≥18 years old) living donor KTR between January 1, 2006
and December 31, 2016 with follow-up until December 31, 2017 were included
in the study. Measurements: The predictive performance of the LKDPI was evaluated. The outcome of
interest was total graft failure, defined as the need for chronic dialysis,
retransplantation, or death with graft function. Methods: The Cox proportional hazards model was used to examine the relation between
the LKDPI and total graft failure. The Cox proportional hazards model was
also used for external validation and performance assessment of the model.
Discrimination and calibration were used to assess model performance.
Discrimination was assessed using Harrell’s C statistic and calibration was
assessed graphically, comparing observed versus predicted probabilities of
total graft failure. Results: A total of 645 living donor KTR were included in the study. The median LKDPI
score was 13 (interquartile range [IQR] = 1.1, 29.9). Higher LKDPI scores
were associated with an increased risk of total graft failure (hazard ratio
= 1.01; 95% confidence interval [CI] = 1.0-1.02; P = .02).
Discrimination was poor (C statistic = 0.55; 95% CI = 0.48-0.61).
Calibration was as good at 1-year posttransplant but suboptimal at 3- and
5-years posttransplant. Limitations: Limitations include a relatively small sample size, predicted probabilities
for assessment of calibration only available for scores of 0 to 100, and
some missing data handled by imputation. Conclusions: In this external validation study, the predictive ability of the LKDPI was
modest in a cohort of Canadian KTR. Validation of prediction models is an
important step to assess performance in external populations. Potential
recalibration of the LKDPI may be useful prior to clinical use in external
cohorts.
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Affiliation(s)
- Mohamed Shantier
- The Kidney Transplant Program and the Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada.,Division of Nephrology, Department of Medicine, University of Toronto, ON, Canada
| | - Yanhong Li
- The Kidney Transplant Program and the Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada
| | - Monika Ashwin
- The Kidney Transplant Program and the Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada
| | - Olsegun Famure
- The Kidney Transplant Program and the Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada
| | - Sunita K Singh
- The Kidney Transplant Program and the Multi-Organ Transplant Program, University Health Network, Toronto, ON, Canada.,Division of Nephrology, Department of Medicine, University of Toronto, ON, Canada.,Toronto General Hospital, University Health Network, ON, Canada
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15
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C4 article: Challenges and solutions to appropriate and timely medication access in transplantation in the United States. Am J Transplant 2020; 20:362-376. [PMID: 31814278 DOI: 10.1111/ajt.15732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 11/20/2019] [Accepted: 11/21/2019] [Indexed: 01/25/2023]
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16
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Kadatz M, Gill JS, Gill J, Formica RN, Klarenbach S. Economic Evaluation of Extending Medicare Immunosuppressive Drug Coverage for Kidney Transplant Recipients in the Current Era. J Am Soc Nephrol 2019; 31:218-228. [PMID: 31704739 DOI: 10.1681/asn.2019070646] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 09/28/2019] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Kidney transplant recipients must take immunosuppressant drugs to prevent rejection and maintain transplant function. Medicare coverage of immunosuppressant drugs for kidney transplant recipients ceases 36 months after transplantation, potentially increasing the risk of transplant failure. A contemporary economic analysis of extending Medicare coverage for the duration of transplant survival using current costs of immunosuppressant medications in the era of generic equivalents may inform immunosuppressant drug policy. METHODS A Markov model was used to determine the incremental cost and effectiveness of extending Medicare coverage for immunosuppressive drugs over the duration of transplant survival, compared with the current policy of 36-month coverage, from the perspective of the Medicare payer. The expected improvement in transplant survival by extending immunosuppressive drug coverage was estimated from a cohort of privately insured transplant recipients who receive lifelong immunosuppressant drug coverage compared with a cohort of Medicare-insured transplant recipients, using multivariable survival analysis. RESULTS Extension of immunosuppression Medicare coverage for kidney transplant recipients led to lower costs of -$3077 and 0.37 additional quality-adjusted life years (QALYs) per patient. When the improvement in transplant survival associated with extending immunosuppressant coverage was reduced to 50% of that observed in privately insured patients, the strategy of extending drug coverage had an incremental cost-utility ratio of $51,694 per QALY gained. In a threshold analysis, the extension of immunosuppression coverage was cost-effective at a willingness-to-pay threshold of $100,000, $50,000, and $0 per QALY if it results in a decrease in risk of transplant failure of 5.5%, 7.8%, and 13.3%, respectively. CONCLUSIONS Extending immunosuppressive drug coverage under Medicare from the current 36 months to the duration of transplant survival will result in better patient outcomes and cost-savings, and remains cost-effective if only a fraction of anticipated benefit is realized.
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Affiliation(s)
| | - John S Gill
- Division of Nephrology and .,Centre for Health Evaluation and Outcomes Sciences, University of British Columbia, Vancouver, British Columbia, Canada.,Division of Nephrology, Tufts-New England Medical Center, Boston, Massachusetts
| | - Jagbir Gill
- Division of Nephrology and.,Centre for Health Evaluation and Outcomes Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Richard N Formica
- Division of Nephrology, Yale University School of Medicine, New Haven, Connecticut; and
| | - Scott Klarenbach
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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17
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Aubert O, Reese PP, Audry B, Bouatou Y, Raynaud M, Viglietti D, Legendre C, Glotz D, Empana JP, Jouven X, Lefaucheur C, Jacquelinet C, Loupy A. Disparities in Acceptance of Deceased Donor Kidneys Between the United States and France and Estimated Effects of Increased US Acceptance. JAMA Intern Med 2019; 179:1365-1374. [PMID: 31449299 PMCID: PMC6714020 DOI: 10.1001/jamainternmed.2019.2322] [Citation(s) in RCA: 111] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
IMPORTANCE Approximately 3500 donated kidneys are discarded in the United States each year, drawing concern from Medicare and advocacy groups. OBJECTIVE To estimate the effects of more aggressive allograft acceptance practices on the donor pool and allograft survival for the population of US wait-listed kidney transplant candidates. DESIGN, SETTING, AND PARTICIPANTS A nationwide study using validated registries from the United States and France comprising comprehensive cohorts of deceased donors with organs offered to kidney transplant centers between January 1, 2004, and December 31, 2014. Data were analyzed between September 1, 2018, and April 5, 2019. MAIN OUTCOMES AND MEASURES The primary outcome was kidney allograft discard. The secondary outcome was allograft failure after transplantation. We used logistic regression to model organ acceptance and discard practices in both countries. We then quantified using computer simulation models the number of kidneys discarded in the United States that a more aggressive system would have instead used for transplantation. Finally, based on actual survival data, we quantified the additional years of allograft life that a redesigned US system would have saved. FINDINGS In the United States, 156 089 kidneys were recovered from deceased donors between 2004 and 2014, of which 128 102 were transplanted, and 27 987 (17.9%) were discarded. In France, among the 29 984 kidneys recovered between 2004 and 2014, 27 252 were transplanted, and 2732 (9.1%, P < .001 vs United States) were discarded. The mean (SD) age of kidneys transplanted in the United States was 36.51 (17.02) years vs 50.91 (17.34) years in France (P < .001). Kidney quality showed little change in the United States over time (mean [SD] kidney donor risk index [KDRI], 1.30 [0.48] in 2004 vs 1.32 [0.46] in 2014), whereas a steadily rising KDRI in France reflected a temporal trend of more aggressive organ use (mean [SD] KDRI, 1.37 [0.47] in 2004 vs 1.74 [0.72] in 2014; P < .001). We applied the French-based allocation model to the population of US deceased donor kidneys and found that 17 435 (62%) of kidneys discarded in the United States would have instead been transplanted under the French system. We further determined that a redesigned system with more aggressive organ acceptance practices would generate an additional 132 445 allograft life-years in the United States over the 10-year observation period. CONCLUSIONS AND RELEVANCE Greater acceptance of kidneys from deceased donors who are older and have more comorbidities could provide major survival benefits to the population of US wait-listed patients. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03723668.
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Affiliation(s)
- Olivier Aubert
- Paris Translational Research Center for Organ Transplantation, INSERM, UMR-S970, Paris, France.,Department of Kidney Transplantation, Necker Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Peter P Reese
- Paris Translational Research Center for Organ Transplantation, INSERM, UMR-S970, Paris, France.,Department of Medicine, Renal-Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Benoit Audry
- Agence de la Biomédecine, Saint Denis la Plaine, France
| | - Yassine Bouatou
- Paris Translational Research Center for Organ Transplantation, INSERM, UMR-S970, Paris, France.,Department of Nephrology and Kidney Transplantation, Saint-Louis Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Marc Raynaud
- Paris Translational Research Center for Organ Transplantation, INSERM, UMR-S970, Paris, France
| | - Denis Viglietti
- Paris Translational Research Center for Organ Transplantation, INSERM, UMR-S970, Paris, France.,Department of Nephrology and Kidney Transplantation, Saint-Louis Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Christophe Legendre
- Paris Translational Research Center for Organ Transplantation, INSERM, UMR-S970, Paris, France.,Department of Kidney Transplantation, Necker Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Denis Glotz
- Paris Translational Research Center for Organ Transplantation, INSERM, UMR-S970, Paris, France.,Department of Nephrology and Kidney Transplantation, Saint-Louis Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Jean-Phillipe Empana
- Paris Translational Research Center for Organ Transplantation, INSERM, UMR-S970, Paris, France
| | - Xavier Jouven
- Paris Translational Research Center for Organ Transplantation, INSERM, UMR-S970, Paris, France
| | - Carmen Lefaucheur
- Paris Translational Research Center for Organ Transplantation, INSERM, UMR-S970, Paris, France.,Department of Nephrology and Kidney Transplantation, Saint-Louis Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Christian Jacquelinet
- Agence de la Biomédecine, Saint Denis la Plaine, France.,INSERM U1018, CESP, Université Paris Sud, Villejuif, France
| | - Alexandre Loupy
- Paris Translational Research Center for Organ Transplantation, INSERM, UMR-S970, Paris, France.,Department of Kidney Transplantation, Necker Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
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18
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Lehner LJ, Kleinsteuber A, Halleck F, Khadzhynov D, Schrezenmeier E, Duerr M, Eckardt KU, Budde K, Staeck O. Assessment of the Kidney Donor Profile Index in a European cohort. Nephrol Dial Transplant 2019; 33:1465-1472. [PMID: 29617898 DOI: 10.1093/ndt/gfy030] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 01/23/2018] [Indexed: 12/26/2022] Open
Abstract
Background Recently, transplant societies have had to change their allocation policies to counter global organ shortages. However, strategies differ significantly and long-term outcomes and cross-regional applicability remain to be evaluated. Methods Therefore, we retrospectively analysed the Kidney Donor Profile Index (KDPI) of 987 adult kidney transplants at our centre using data from the Organ Procurement and Transplantation Network (OPTN) as a reference. Results In our cohort, the median KDPI was 66%, with a higher proportion of >85% KDPI kidneys compared with the US cohort (32.3% versus 9.2%). Among elderly patients (≥65 years of age), 62% received >95% KDPI kidneys, which were primarily allocated within the Eurotransplant Senior Program (ESP). After 10 years, the rate of death-censored graft survival was 70.5%. Recipients of >85% KDPI kidneys were significantly older, demonstrating higher mortality, poorer graft survival and lower estimated glomerular filtration rate. Patients receiving ≥99% KDPI kidneys had a satisfactory 5-year death-censored graft survival (72.9%). The 5-year survival rate of patients living with a functioning graft exceeded the matched OPTN data in the whole KDPI range, despite a higher proportion of elderly recipients. Multivariate analysis revealed KDPI as an independent risk factor for graft loss (hazard ratio 1.14/10%, P < 0.001), although C-statistics of 0.62 indicated limited discriminative ability for individuals. Conclusion The analysis demonstrated KDPI as a potentially useful tool for donor quality assessment in a European cohort. Most importantly, our analysis revealed acceptable outcomes even for very high KDPI kidneys.
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Affiliation(s)
- Lukas Johannes Lehner
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Anna Kleinsteuber
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Fabian Halleck
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Dmytro Khadzhynov
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Eva Schrezenmeier
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Michael Duerr
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Kai-Uwe Eckardt
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Oliver Staeck
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
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19
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Wesolowska-Gorniak K, Wojtowicz M, Gierus J, Wlodarczyk E, Federowicz M, Czarkowska-Paczek B. Multivariate analysis of biopsychosocial determinants of professional activity among patients after kidney or liver transplantation in Poland. BMJ Open 2019; 9:e029501. [PMID: 31292184 PMCID: PMC6624034 DOI: 10.1136/bmjopen-2019-029501] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVE The aim of the present study was to assess the employment rate among kidney and liver transplant recipients in Poland and identify the predictors of employment. SETTINGS The study was based on a self-prepared questionnaire containing five parts: demographic data and professional, medical, physical and psychological factors. This is a multicentre study involving four hospitals in Poland. PARTICIPANTS The investigated group consisted of 285 individuals (92 women and 185 men; 8 no sex given) aged between 18 and 45 years who underwent kidney or liver transplantation 1-5 years prior. Because of missing data, 279 questionnaires were considered regarding employment status after transplantation and 277 when sex differences were considered. RESULTS A total of 120 patients (43%) worked full-time, 42 (15%) part-time and 117 (42%) remained unemployed, with a higher employment rate post-transplantation among men than women (60% vs 55%, p=0.04). More women performed white collar work (74% vs 41%, p=0.0003) and had to modify their working position than men (22% vs 7%, p=0.0118). Factors determining employment after transplantation included higher level of education (OR=27.08; p=0.0096), employment 1 year prior to transplantation (OR=11.05; p<0.001) and good psychological adaptation (OR=4.23; p<0.001). Men working the year before transplantation had higher education (OR=9.66; p=0.0356). Among men, more kidney recipients worked compared with liver recipients (OR=3.567; p=0.0417). Among women, age determined employment status (OR=0.89; p=0.0234). CONCLUSION Higher education is the most important predictor of employment after transplantation. Therefore, rehabilitation programmes including vocational activity should be directed to increase the level of education, both pretransplantation and post-transplantation if possible.
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Affiliation(s)
| | - Monika Wojtowicz
- Department of Immunology, Transplantology, and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Jacek Gierus
- Clinic of Psychiatry, Medical University of Warsaw, Pruszkow, Poland
| | - Elzbieta Wlodarczyk
- Department of Geriatrics, Collegium Medicum, Nicolaus Copernicus University in Torun, Bydgoszcz, Poland
| | - Magdalena Federowicz
- Department of Rehabilitation, Central Teaching Clinical Hospital in Warsaw, Warsaw, Poland
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20
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Hart A, Gustafson SK, Wey A, Salkowski N, Snyder JJ, Kasiske BL, Israni AK. The association between loss of Medicare, immunosuppressive medication use, and kidney transplant outcomes. Am J Transplant 2019; 19:1964-1971. [PMID: 30838768 PMCID: PMC6785998 DOI: 10.1111/ajt.15293] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 01/04/2019] [Accepted: 01/22/2019] [Indexed: 01/25/2023]
Abstract
Kidney transplant recipients aged <65 years qualify for Medicare coverage, but coverage ends 3 years posttransplant. We determined the association between timing of Medicare loss and immunosuppressive medication fills and kidney allograft loss. Using data from the Scientific Registry of Transplant Recipients (SRTR), US Renal Data System, and Symphony pharmacy fill database, we analyzed 78 861 Medicare-covered, kidney-alone recipients aged <65 years, and assessed the timing of Medicare loss posttransplant: early (<3 years), on-time (at 3 years), or late (>3 years). Immunosuppressant use was measured as medication possession ratio (MPR). Allograft loss was assessed using SRTR data. MPR was lower for recipients with early or late Medicare loss compared with no coverage loss for all immunosuppressive medication types. For calcineurin inhibitors, early Medicare loss was associated with a 53% to 86% lower MPR. On-time Medicare loss was not associated with a lower MPR. When recipients were matched by age, posttransplant timing of Medicare loss, and donor risk, the hazard of allograft loss was 990% to 1630% higher after early Medicare loss, and 140% to 740% higher after late Medicare loss, with no difference in the hazard for on-time Medicare loss. Ensuring ongoing Medicare access before and after 3 years posttransplant could affect graft survival.
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Affiliation(s)
- Allyson Hart
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota,Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota
| | - Sally K. Gustafson
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - Andrew Wey
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - Nicholas Salkowski
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - Jon J. Snyder
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota,Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota
| | - Bertram L. Kasiske
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota,Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota
| | - Ajay K. Israni
- Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, Minnesota,Department of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota
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21
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Wesolowska-Gorniak K, Gierus J, Wojtowicz M, Bugajska J, Czarkowska-Paczek B. Determinants of Professional Activity After Kidney and Liver Transplantation: Questionnaire Development and Validation. Transplant Proc 2019; 51:651-664. [PMID: 30979448 DOI: 10.1016/j.transproceed.2018.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Organ transplantation is currently the treatment of choice in end-stage organ failure. Organ replacement therapy compensates for most of organ function loss and offers recipients the potential for an independent life; nevertheless, the employment rate after kidney or liver transplant is low vs the general population. The purpose of this study was to create a questionnaire for kidney and liver transplant patients that comprehensively assesses factors affecting employment among these people including demographic, physical, and psychosocial variables. MATERIAL AND METHODS The study was based on a self-prepared questionnaire developed by a team of specialists in the field of medicine, rehabilitation, psychology, and employment. The questionnaire contained 5 parts: demographic data, professional factors, medical factors, physical factors, and psychological factors. The normalization sample consisted of 64 individuals (women and men) aged between 18 to 45 years 1 to 5 years after kidney or liver transplant. The Determinants of Professional Activity after Kidney and Liver Transplantation Questionnaire (DPATQ) was developed based on descriptive statistics, Spearman ρ coefficient, principal component analysis, Cronbach α, and item response theory analysis. RESULTS The Cronbach α reliability coefficient for the psychological part reached 0.88. CONCLUSION The DPATQ is a new method for measuring post-transplant adaptation and other factors influencing employment status. It offers good psychometric reliability. The DPATQ may be useful in the preparation process of vocational rehabilitation programs or in research studying problems with employment after solid organ transplant.
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Affiliation(s)
| | - J Gierus
- Psychiatric Clinic, Medical University of Warsaw, Pruszkow, Poland
| | - M Wojtowicz
- Department of Immunology, Transplantology, and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - J Bugajska
- Central Institute for Labor Protection, National Research Institute, Warsaw, Poland
| | - B Czarkowska-Paczek
- Department of Clinical Nursing, Medical University of Warsaw, Warsaw, Poland.
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22
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Potter LM. Are Generic Immunosuppressive Drugs the Solution for Providing Lifelong Medication Coverage to Transplant Recipients? Clin J Am Soc Nephrol 2019; 14:327-329. [PMID: 30819668 PMCID: PMC6419283 DOI: 10.2215/cjn.00960119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Lisa M. Potter
- Department of Pharmacy and
- Transplant Institute, University of Chicago Medicine, Chicago, Illinois
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23
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Harhay MN, McKenna RM, Boyle SM, Ranganna K, Mizrahi LL, Guy S, Malat GE, Xiao G, Reich DJ, Harhay MO. Association between Medicaid Expansion under the Affordable Care Act and Preemptive Listings for Kidney Transplantation. Clin J Am Soc Nephrol 2018; 13:1069-1078. [PMID: 29929999 PMCID: PMC6032587 DOI: 10.2215/cjn.00100118] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 04/13/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND AND OBJECTIVES Before 2014, low-income individuals in the United States with non-dialysis-dependent CKD had fewer options to attain health insurance, limiting their opportunities to be preemptively wait-listed for kidney transplantation. We examined whether expanding Medicaid under the Affordable Care Act was associated with differences in the number of individuals who were pre-emptively wait-listed with Medicaid coverage. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Using the United Network of Organ Sharing database, we performed a retrospective observational study of adults (age≥18 years) listed for kidney transplantation before dialysis dependence between January 1, 2011-December 31, 2013 (pre-Medicaid expansion) and January 1, 2014-December 31, 2016 (post-Medicaid expansion). In multinomial logistic regression models, we compared trends in insurance types used for pre-emptive wait-listing in states that did and did not expand Medicaid with a difference-in-differences approach. RESULTS States that fully implemented Medicaid expansion on January 1, 2014 ("expansion states," n=24 and the District of Columbia) had a 59% relative increase in Medicaid-covered pre-emptive listings from the pre-expansion to postexpansion period (from 1094 to 1737 listings), compared with an 8.8% relative increase (from 330 to 359 listings) among 19 Medicaid nonexpansion states (P<0.001). From the pre- to postexpansion period, the adjusted proportion of listings with Medicaid coverage decreased by 0.3 percentage points among nonexpansion states (from 4.0% to 3.7%, P=0.09), and increased by 3.0 percentage points among expansion states (from 7.0% to 10.0%, P<0.001). Medicaid expansion was associated with absolute increases in Medicaid coverage by 1.4 percentage points among white listings, 4.0 percentage points among black listings, 5.9 percentage points among Hispanic listings, and 5.3 percentage points among other listings (P<0.001 for all comparisons). CONCLUSIONS Medicaid expansion was associated with an increase in the proportion of new pre-emptive listings for kidney transplantation with Medicaid coverage, with larger increases in Medicaid coverage among racial and ethnic minority listings than among white listings.
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Affiliation(s)
- Meera N. Harhay
- Division of Nephrology and Hypertension, Department of Medicine, and
- Epidemiology and Biostatistics and
| | - Ryan M. McKenna
- Health Management and Policy, Drexel University Dornsife School of Public Health, Philadelphia, Pennsylvania
| | - Suzanne M. Boyle
- Division of Nephrology and Hypertension, Department of Medicine, and
| | - Karthik Ranganna
- Division of Nephrology and Hypertension, Department of Medicine, and
| | | | - Stephen Guy
- Division of Multi-Organ Transplantation and Hepatobiliary Surgery, Department of Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania; Departments of
| | - Gregory E. Malat
- Division of Multi-Organ Transplantation and Hepatobiliary Surgery, Department of Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania; Departments of
| | - Gary Xiao
- Division of Multi-Organ Transplantation and Hepatobiliary Surgery, Department of Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania; Departments of
| | - David J. Reich
- Division of Multi-Organ Transplantation and Hepatobiliary Surgery, Department of Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania; Departments of
| | - Michael O. Harhay
- Palliative and Advanced Illness Research Center and
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, and
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; and
- Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center, Pennsylvania
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Châtelet V, Bayat-Makoei S, Vigneau C, Launoy G, Lobbedez T. Renal transplantation outcome and social deprivation in the French healthcare system: a cohort study using the European Deprivation Index. Transpl Int 2018; 31:1089-1098. [DOI: 10.1111/tri.13161] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 01/15/2018] [Accepted: 03/22/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Valérie Châtelet
- Centre Universitaire des Maladies Rénales; CHU de Caen; Caen Cedex 9 France
| | | | | | - Guy Launoy
- Centre de Lutte Contre le Cancer François Baclesse; U1086 Inserm, ‘ANTICIPE’; Caen Cedex 05 France
| | - Thierry Lobbedez
- Centre Universitaire des Maladies Rénales; CHU de Caen; Caen Cedex 9 France
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Steinberg EA, Moss M, Buchanan CL, Goebel J. Adherence in pediatric kidney transplant recipients: solutions for the system. Pediatr Nephrol 2018; 33:361-372. [PMID: 28349215 DOI: 10.1007/s00467-017-3637-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 02/24/2017] [Accepted: 02/27/2017] [Indexed: 12/13/2022]
Abstract
Non-adherence remains a significant problem among pediatric (and adult) renal transplant recipients. Non-adherence among solid organ transplant recipients results in US$15-100 million annual costs. Estimates of non-adherence range from 30 to 70% among pediatric patients. Research demonstrates that a 10% decrement in adherence is associated with 8% higher hazard of graft failure and mortality. Focus has begun to shift from patient factors that impact adherence to the contributing healthcare and systems factors. The purpose of this review is to describe problems within the systems implicated in non-adherence and potential solutions that may be related to positive adherence outcomes. Systems issues include insurance and legal regulations, provider and care team barriers to optimal care, and difficulties with transitioning to adult care. Potential solutions include recognition of how systems can work together to improve patient outcomes through improvements in insurance programs, a multi-disciplinary care team approach, evidence-based medical management, pharmacy-based applications and interventions to simplify medication regimens, improved transition protocols, and telehealth/technology-based multi-component interventions. However, there remains a significant lack of reliability in the application of these potential solutions to systems issues that impact patient adherence. Future efforts should accordingly focus on these efforts, likely by leveraging quality improvement and related principles, and on the investigation of the efficacy of these interventions to improve adherence and graft outcomes.
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Affiliation(s)
- Elizabeth A Steinberg
- Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Mary Moss
- Department of Pharmacy, Children's Hospital Colorado, Aurora, CO, USA
| | - Cindy L Buchanan
- Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO, USA.,Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jens Goebel
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
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Depression and Immunosuppressive Therapy Adherence Following Renal Transplantation in Military Healthcare System Beneficiaries. Kidney Int Rep 2017; 2:248-250. [PMID: 29142960 PMCID: PMC5678652 DOI: 10.1016/j.ekir.2016.10.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Revised: 10/12/2016] [Accepted: 10/19/2016] [Indexed: 11/24/2022] Open
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McSorley AMM, Peipert JD, Gonzalez C, Norris KC, Goalby CJ, Peace LJ, Waterman AD. Dialysis Providers’ Perceptions of Barriers to Transplant for Black and Low-Income Patients: A Mixed Methods Analysis Guided by the Socio-Ecological Model for Transplant. WORLD MEDICAL & HEALTH POLICY 2017. [DOI: 10.1002/wmh3.251] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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28
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Shen JI, Hercz D, Barba LM, Wilhalme H, Lum EL, Huang E, Reddy U, Salas L, Vangala S, Norris KC. Association of Citizenship Status With Kidney Transplantation in Medicaid Patients. Am J Kidney Dis 2017; 71:182-190. [PMID: 29128413 DOI: 10.1053/j.ajkd.2017.08.014] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 08/07/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Although individuals classified as nonresident aliens, including undocumented immigrants, are entitled to receive emergency dialysis in the United States regardless of their ability to pay, most states do not provide them with subsidized care for maintenance dialysis or kidney transplantation. We explored whether nonresident aliens have similar outcomes to US citizens after receiving kidney transplants covered by Medicaid, a joint federal and state health insurance program. STUDY DESIGN Retrospective observational cohort study. SETTING & PARTICIPANTS All adult Medicaid patients in the US Renal Data System who received their first kidney transplant from 1990 to 2011. PREDICTOR Citizenship status, categorized as US citizen, nonresident alien, or permanent resident. OUTCOME All-cause transplant loss. MEASUREMENTS HRs and 95% CIs estimated by applying Cox proportional hazards frailty models with transplantation center as a random effect. RESULTS Of 10,495 patients, 8,660 (82%) were US citizens, 1,489 (14%) were permanent residents, and 346 (3%) were nonresident aliens, whom we assumed were undocumented immigrants. Nonresident aliens were younger, healthier, receiving dialysis longer, and more likely to have had a living donor. 71% underwent transplantation in California, and 61% underwent transplantation after 2005. Nonresident aliens had a lower unadjusted risk for transplant loss compared with US citizens (HR, 0.48; 95% CI, 0.35-0.65). Results were attenuated but still significant when adjusted for demographics, comorbid conditions, dialysis, and transplant-related factors (HR, 0.67; 95% CI, 0.46-0.94). LIMITATIONS Citizenship status was self-reported, possible residual confounding. CONCLUSIONS Our study suggests that the select group of insured nonresident aliens who undergo transplantation with Medicaid do just as well as US citizens with Medicaid. Policymakers should consider expanding coverage for kidney transplantation in nonresident aliens, including undocumented immigrants, given the associated high-quality outcomes in these patients.
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Affiliation(s)
- Jenny I Shen
- Division of Nephrology and Hypertension, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA; Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA.
| | - Daniel Hercz
- Department of Medicine Statistics Core, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Lilly M Barba
- Division of Nephrology and Hypertension, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA; Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Holly Wilhalme
- Department of Medicine Statistics Core, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Erik L Lum
- Division of Nephrology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Edmund Huang
- Division of Nephrology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Uttam Reddy
- Division of Nephrology and Hypertension, University of California Irvine, Orange, CA
| | - Leslie Salas
- Division of Nephrology and Hypertension, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA
| | - Sitaram Vangala
- Department of Medicine Statistics Core, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Keith C Norris
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA
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Hucker A, Bunn F, Carpenter L, Lawrence C, Farrington K, Sharma S. Non-adherence to immunosuppressants following renal transplantation: a protocol for a systematic review. BMJ Open 2017; 7:e015411. [PMID: 28963283 PMCID: PMC5640118 DOI: 10.1136/bmjopen-2016-015411] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Adherence to immunosuppressant medication is essential for renal transplant recipients. This review aims to summarise what is known about non-adherence, with a view to providing comprehensive evidence to inform strategies aimed at advancing adherent behaviour. METHODS AND ANALYSIS A systematic review of quantitative studies that report adherence to immunosuppressants in adult (over 18 years) renal transplant recipients. The review will follow the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines; study quality will be assessed using the Downs and Black checklist. Systematic searches will be completed across relevant databases. Two reviewers will independently extract data using a predefined data extraction form. We will summarise the operationalisation of adherence across studies and use narrative synthesis to identify factors associated with non-adherence. A meta-analysis will be conducted if there is sufficient homogeneity, and available data, across studies to estimate the prevalence of non-adherence in renal transplant recipients. Heterogeneity will be assessed using the I2 test. Survival analysis will be conducted to estimate hazard ratios to explore the impact of non-adherence on graft survival, graft failure and patient survival. ETHICS AND DISSEMINATION Findings will be published in a peer-reviewed journal and disseminated at conferences for professionals and researchers. Review outcomes will help support clinical practice by highlighting the extent of non-adherence among adults, and in doing so, signpost the need for suitable intervention. TRIAL REGISTRATION NUMBER PROSPERO registration number (CRD42016038751).
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Affiliation(s)
- Abigail Hucker
- Department of Psychology and Sport Sciences, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - Frances Bunn
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, UK
| | - Lewis Carpenter
- Department of Psychology and Sport Sciences, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | | | - Ken Farrington
- Renal Unit, Lister Hospital, Stevenage, Hertfordshire, UK
| | - Shivani Sharma
- Department of Psychology and Sport Sciences, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
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Harding K, Mersha TB, Pham PT, Waterman AD, Webb FA, Vassalotti JA, Nicholas SB. Health Disparities in Kidney Transplantation for African Americans. Am J Nephrol 2017; 46:165-175. [PMID: 28787713 DOI: 10.1159/000479480] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The persistent challenges of bridging healthcare disparities for African Americans (AAs) in need of kidney transplantation continue to be unresolved at the national level. This healthcare disparity is multifactorial: stemming from limited kidney donors suitable for AAs; inconsistent care coordination and suboptimal risk factor control; social determinants, low socioeconomic status, reduced access to care; and mistrust of clinicians and the healthcare system. SUMMARY There are numerous opportunities to significantly lessen the disparities in kidney transplantation for AAs through the following measures: the adoption of new care and patient engagement models that include education, enhanced practice-level cultural sensitivity, and timely referral as well as increased research on the impact of the environment on genetic risk, and implementation of new transplantation-related policies. Key Messages: This systematic review describes pretransplant concerns related to access to kidney transplantation, posttransplant complications, and policy interventions to address the challenging issues associated with kidney transplantation in AAs.
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Infectious complications as the leading cause of death after kidney transplantation: analysis of more than 10,000 transplants from a single center. J Nephrol 2017; 30:601-606. [PMID: 28211034 DOI: 10.1007/s40620-017-0379-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 01/12/2017] [Indexed: 02/02/2023]
Abstract
AIM To identify specific causes of graft failure in a large sample of kidney transplant patients from a middle-income, developing country. METHODS Retrospective cohort study analyzing all consecutive single kidney transplants (KTs) performed at a single center in Brazil between January 1st 1998 and December 31st 2013. The database closing date was December 31st 2014. RESULTS Out of 10,400 KTs, there were 1191 (11.45%) deaths with a functioning graft, 40 cases (0.38%) of primary non-function (PNF) and 1417 cases (13.62%) of graft loss excluding death and PNF as the cause. Infectious complications (404 cases, 34% of all deaths) were the major cause of death. Most deaths due to infection occurred within the first year after transplantation (157 deaths, 38.86%). Immunologic mechanisms, comprising acute rejection and immune-mediated interstitial fibrosis/tubular atrophy (IF/TA), were responsible for 52% of all cases of graft failure not involving recipient death. Half of the losses by acute rejection occurred late after transplantation. CONCLUSION Contrary to what is observed in developed countries, infectious complications are the main challenge with kidney transplantation in Brazil. Non-adherence to treatment also appears to contribute significantly to long-term kidney graft loss. Strategies for improvement should focus on better compliance and a greater safety profile of immunosuppressive treatment.
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Ansell D, Pallok K, Guzman MD, Flores M, Oberholzer J. Illinois law opens door to kidney transplants for undocumented immigrants. Health Aff (Millwood) 2016; 34:781-7. [PMID: 25941279 DOI: 10.1377/hlthaff.2014.1192] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- David Ansell
- David Ansell is a primary care physician in the Department of Internal Medicine and senior vice president for system integration, both at Rush University Medical Center, in Chicago, Illinois
| | - Kristen Pallok
- Kristen Pallok is a medical student at Rush Medical College, in Chicago
| | - Marieli D Guzman
- Marieli D. Guzman is a research assistant in the Department of Preventive Medicine at Rush University Medical Center and a matriculating medical student
| | - Marycarmen Flores
- Marycarmen Flores is a senior at Bates College, in Lewiston, Maine, and a former summer health disparity intern at Rush University Medical Center
| | - Jose Oberholzer
- Jose Oberholzer is chief of abdominal transplant surgery in the Department of Surgery, College of Medicine, the University of Illinois at Chicago
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Laidouni N, Gil-González D, Latorre-Arteaga S. Barriers to Organ Transplantation in the Algerian Health System from the Perspective of Health Professionals: A Qualitative Approach. Transplant Proc 2016; 48:3261-3267. [DOI: 10.1016/j.transproceed.2016.08.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 07/29/2016] [Accepted: 08/22/2016] [Indexed: 11/25/2022]
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Early Kidney Allograft Dysfunction (Threatened Allograft): Comparative Effectiveness of Continuing Versus Discontinuation of Tacrolimus and Use of Sirolimus to Prevent Graft Failure: A Retrospective Patient-Centered Outcome Study. Transplant Direct 2016; 2:e98. [PMID: 27795990 PMCID: PMC5068206 DOI: 10.1097/txd.0000000000000585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 03/14/2016] [Indexed: 12/02/2022] Open
Abstract
Supplemental digital content is available in the text. Background Due to lack of treatment options for early acute allograft dysfunction in the presence of tubular-interstitial injury without histological features of rejection, kidney transplant recipients are often treated with sirolimus-based therapy to prevent cumulative calcineurin inhibitor exposure and to prevent premature graft failure. Methods We analyzed transplant recipients treated with sirolimus-based (n = 220) compared with continued tacrolimus-based (n = 276) immunosuppression in recipients of early-onset graft dysfunction (threatened allograft) with the use of propensity score-based inverse probability treatment weighted models to balance for potential confounding by indication between 2 nonrandomized groups. Results Weighted odds for death-censored graft failure (odds ratio [OR], 1.20; 95% confidence interval [95% CI], 0.66-2.19, P = 0.555) was similar in the 2 groups, but a trend for increased risk of greater than 50% loss in estimated glomerular filtration rate from baseline in sirolimus group (OR, 1.90; 95% CI, 0.96-3.76; P = 0.067) compared with tacrolimus group. Sirloimus group compared with tacrolimus group had increased risk for death with functioning graft (OR, 2.01; 95% CI, 1.29-3.14; P = 0.002) as well as increased risk of late death (death after graft failure while on dialysis) (OR, 2.39; 95% CI, 1.59-3.59; P < 0.001). Analysis of subgroups based on the absence or presence of T cell–mediated rejection or tubulointerstitial inflammation in the index biopsy, or the use of different types of induction agents, and all subgroups had increased risk of death with functioning graft and late death if exposed to sirolimus-based therapy. Conclusions Use of sirolimus compared with tacrolimus in recipients with early allograft dysfunction during the first year of transplant may not prevent worsening of allograft function and could potentially lead to poor survival along with increased risk of late death.
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Halloran PF, Famulski KS, Reeve J. Molecular assessment of disease states in kidney transplant biopsy samples. Nat Rev Nephrol 2016; 12:534-48. [DOI: 10.1038/nrneph.2016.85] [Citation(s) in RCA: 108] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Hu M, Wang YM, Wang Y, Zhang GY, Zheng G, Yi S, O'Connell PJ, Harris DCH, Alexander SI. Regulatory T cells in kidney disease and transplantation. Kidney Int 2016; 90:502-14. [PMID: 27263492 DOI: 10.1016/j.kint.2016.03.022] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 03/06/2016] [Accepted: 03/17/2016] [Indexed: 01/03/2023]
Abstract
Regulatory T cells (Tregs) have been shown to be important in maintaining immune homeostasis and preventing autoimmune disease, including autoimmune kidney disease. It is also likely that they play a role in limiting kidney transplant rejection and potentially in promoting transplant tolerance. Although other subsets of Tregs exist, the most potent and well-defined Tregs are the Foxp3 expressing CD4(+) Tregs derived from the thymus or generated peripherally. These CD4(+)Foxp3(+) Tregs limit autoimmune renal disease in animal models, especially chronic kidney disease, and kidney transplantation. Furthermore, other subsets of Tregs, including CD8 Tregs, may play a role in immunosuppression in kidney disease. The development and protective mechanisms of Tregs in kidney disease and kidney transplantation involve multiple mechanisms of suppression. Here we review the development and function of CD4(+)Foxp3(+) Tregs. We discuss the specific application of Tregs as a therapeutic strategy to prevent kidney disease and to limit kidney transplant rejection and detail clinical trials in this area of transplantation.
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Affiliation(s)
- Min Hu
- Centre for Transplantation and Renal Research, The Westmead Institute for Medical Research, University of Sydney, Westmead, New South Wales, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, University of Sydney, Westmead, New South Wales, Australia
| | - Yuan Min Wang
- Centre for Kidney Research, The Children's Hospital at Westmead, University of Sydney, Westmead, New South Wales, Australia
| | - Yiping Wang
- Centre for Transplantation and Renal Research, The Westmead Institute for Medical Research, University of Sydney, Westmead, New South Wales, Australia
| | - Geoff Y Zhang
- Centre for Kidney Research, The Children's Hospital at Westmead, University of Sydney, Westmead, New South Wales, Australia
| | - Guoping Zheng
- Centre for Transplantation and Renal Research, The Westmead Institute for Medical Research, University of Sydney, Westmead, New South Wales, Australia
| | - Shounan Yi
- Centre for Transplantation and Renal Research, The Westmead Institute for Medical Research, University of Sydney, Westmead, New South Wales, Australia
| | - Philip J O'Connell
- Centre for Transplantation and Renal Research, The Westmead Institute for Medical Research, University of Sydney, Westmead, New South Wales, Australia
| | - David C H Harris
- Centre for Transplantation and Renal Research, The Westmead Institute for Medical Research, University of Sydney, Westmead, New South Wales, Australia
| | - Stephen I Alexander
- Centre for Kidney Research, The Children's Hospital at Westmead, University of Sydney, Westmead, New South Wales, Australia.
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Nerini E, Bruno F, Citterio F, Schena FP. Nonadherence to immunosuppressive therapy in kidney transplant recipients: can technology help? J Nephrol 2016; 29:627-36. [DOI: 10.1007/s40620-016-0273-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 02/03/2016] [Indexed: 10/22/2022]
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Tsipotis E, Gupta NR, Raman G, Zintzaras E, Jaber BL. Bioavailability, Efficacy and Safety of Generic Immunosuppressive Drugs for Kidney Transplantation: A Systematic Review and Meta-Analysis. Am J Nephrol 2016; 44:206-18. [PMID: 27576318 PMCID: PMC6584577 DOI: 10.1159/000449020] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 07/05/2016] [Indexed: 01/07/2023]
Abstract
BACKGROUND Concerns exist over the extrapolation of bioavailability studies of generic immunosuppressive drugs in healthy volunteers, regarding their efficacy and safety in kidney transplant recipients. We conducted a meta-analysis of trials examining the bioavailability of generic (test) immunosuppressive drugs relative to their brand (reference) counterparts in healthy volunteers, based on the US Food and Drug Administration requirements for approval of generics, and their efficacy and safety in kidney transplant recipients. METHODS Eligible studies were identified in PubMed, Cochrane Central Register of Controlled Trials, Scopus, ClinicalTrials.gov, and conference abstracts. RESULTS Twenty crossover trials of healthy volunteers (n = 641) and 6 parallel-arm randomized controlled trials of kidney transplant recipients (n = 594) were identified. The 90% CI of the pooled test-to-reference drug ratio for maximum or peak plasma concentration (Cmax) and area under the plasma concentration time-curve from time 0 to time of last determinable concentration (AUC(0-t)) fell within the required range (0.80-1.25) for cyclosporine (Cmax 0.91; 90% CI 0.86-0.95; and AUC(0-t) 0.97; 90% CI 0.94-1.00), tacrolimus (Cmax 1.17; 90% CI 1.09-1.24; and AUC(0-t) 1.00; 90% CI 0.97-1.03) and mycophenolate mofetil (Cmax 0.98; 90% CI 0.96-1.01; and AUC(0-t) 1.00; 90% CI 0.99-1.01). In subgroup analyses, some generic cyclosporine formulations did not meet criteria for bioequivalence. No significant differences were observed in the time to maximum plasma concentration and terminal plasma half-life between generic and brand drugs. In parallel-arm trials, generic cyclosporine was non-inferior to brand counterpart in terms of acute allograft rejection, infections, and death. CONCLUSIONS Not all generic immunosuppressive drugs have similar relative bioavailability to their brand name counterparts. Evidence on their efficacy and safety is inconclusive. Tighter regulatory requirement for approval of generic drugs with narrow therapeutic index is needed.
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Affiliation(s)
- Evangelos Tsipotis
- Department of Medicine, Tufts University School of
Medicine, Boston, Mass., USA,Department of Medicine, Division of Nephrology, St.
Elizabeth’s Medical Center, Tufts University School of Medicine, Boston,
Mass., USA
| | - Navin R. Gupta
- Department of Medicine, Tufts University School of
Medicine, Boston, Mass., USA
| | - Gowri Raman
- Center for Clinical Evidence Synthesis, The Institute for
Clinical Research and Health Policy Studies, Tufts Medical Center, Tufts University
School of Medicine, Boston, Mass., USA
| | - Elias Zintzaras
- Center for Clinical Evidence Synthesis, The Institute for
Clinical Research and Health Policy Studies, Tufts Medical Center, Tufts University
School of Medicine, Boston, Mass., USA,Department of Biomathematics, Evidence-Based Medicine Unit,
University of Thessaly School of Medicine, Larissa, Greece
| | - Bertrand L. Jaber
- Department of Medicine, Tufts University School of
Medicine, Boston, Mass., USA,Department of Medicine, Division of Nephrology, St.
Elizabeth’s Medical Center, Tufts University School of Medicine, Boston,
Mass., USA
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Baudelot C, Caillé Y, Godechot O, Mercier S. Maladies rénales et inégalités sociales d’accès à la greffe en France. POPULATION 2016. [DOI: 10.3917/popu.1601.0023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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40
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Ward FL, O'Kelly P, Donohue F, ÓhAiseadha C, Haase T, Pratschke J, deFreitas DG, Johnson H, Conlon PJ, O'Seaghdha CM. Influence of socioeconomic status on allograft and patient survival following kidney transplantation. Nephrology (Carlton) 2015; 20:426-33. [DOI: 10.1111/nep.12410] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Frank L Ward
- Department of Transplantation and Renal Medicine; Beaumont Hospital; Dublin Ireland
| | - Patrick O'Kelly
- Department of Transplantation and Renal Medicine; Beaumont Hospital; Dublin Ireland
| | - Fionnuala Donohue
- Health Intelligence Unit; Health & Wellbeing Directorate; Health Service Executive; Dublin Ireland
| | - Coilin ÓhAiseadha
- Health Intelligence Unit; Health & Wellbeing Directorate; Health Service Executive; Dublin Ireland
| | - Trutz Haase
- Social and Economic Consultant; Health Service Executive; Dublin Ireland
| | - Jonathan Pratschke
- Social and Economic Consultant; Health Service Executive; Dublin Ireland
| | - Declan G deFreitas
- Department of Transplantation and Renal Medicine; Beaumont Hospital; Dublin Ireland
| | - Howard Johnson
- Health Intelligence Unit; Health & Wellbeing Directorate; Health Service Executive; Dublin Ireland
| | - Peter J Conlon
- Department of Transplantation and Renal Medicine; Beaumont Hospital; Dublin Ireland
| | - Conall M O'Seaghdha
- Department of Transplantation and Renal Medicine; Beaumont Hospital; Dublin Ireland
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Abstract
BACKGROUND Patients' adherence with posttransplant immunosuppression is known to affect renal transplant outcomes. METHODS Prospectively, individual medication adherence patterns in 195 kidney transplant recipients were quantified with electronic medication monitors. Monitored drugs were mycophenolate mofetil, sirolimus, or azathioprine. Monitoring began at hospital discharge and continued an average of 15±8 months. Patient follow-up for clinical outcomes averaged 8±3 years. Each month's adherence percentage was calculated as the sum of daily adherence percents, divided by the number of evaluable days. RESULTS During the first 3 months after transplantation, patients (n=44) with declining medication adherence, defined as dropping by 7% or higher (equal to missing 2 days) between months 1 and 2, later experienced lower mean medication adherence for months 6 to 12, 73% versus 92% respectively (P<0.0001). Compared to patients with stable adherence, they also had more frequent (P=0.034) and earlier (P=0.065) acute rejection episodes. This was additionally associated with more frequent (P=0.017) and earlier (P=0.046) death-censored graft loss.In addition, daily medication adherence, expressed as the percentage of doses taken, decreased as the number of prescribed daily doses increased. During the first 3 months after transplantation, adherence with four doses per day averaged 84%, compared to 91% for patients on twice-daily dosing (P=0.024) and 93.5% for patients on once-daily dosing (P=0.008). CONCLUSIONS Early declining medication nonadherence is associated with adverse clinical outcomes. This pattern is detectable during the first 2 months after transplantation. Early detection of nonadherence provides opportunities to target interventions toward patients at the highest risk for adverse behaviors and events.
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Kim SJ, Fenton SS, Kappel J, Moist LM, Klarenbach SW, Samuel SM, Singer LG, Kim DH, Young K, Webster G, Wu J, Ivis F, de Sa E, Gill JS. Organ donation and transplantation in Canada: insights from the Canadian Organ Replacement Register. Can J Kidney Health Dis 2014; 1:31. [PMID: 25780620 PMCID: PMC4349751 DOI: 10.1186/s40697-014-0031-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 11/18/2014] [Indexed: 02/01/2023] Open
Abstract
PURPOSE OF REVIEW To provide an overview of the transplant component of the Canadian Organ Replacement Register (CORR). FINDINGS CORR is the national registry of organ failure in Canada. It has existed in some form since 1972 and currently houses data on patients with end-stage renal disease and solid organ transplants (kidney and/or non-kidney). The transplant component of CORR receives data on a voluntary basis from individual transplant centres and organ procurement organizations across the country. Coverage for transplant procedures is comprehensive and complete. Long-term outcomes are tracked based on follow-up reports from participating transplant centres. The longitudinal nature of CORR provides an opportunity to observe the trajectory of a patient's journey with organ failure over their life span. Research studies conducted using CORR data inform both practitioners and health policy makers alike. IMPLICATIONS The importance of registry data in monitoring and improving care for Canadian transplant candidates/recipients cannot be over-stated. This paper provides an overview of the transplant data in CORR including its history, data considerations, recent findings, new initiatives, and future directions.
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Affiliation(s)
- Sang Joseph Kim
- Department of Medicine, Division of Nephrology, University of Toronto, 585 University Avenue, 11-PMB-129, Toronto, ON M5G 2 N2 Canada ; Multi-Organ Transplant Program, University Health Network, Toronto, ON Canada
| | - Stanley Sa Fenton
- Department of Medicine, Division of Nephrology, University of Toronto, 585 University Avenue, 11-PMB-129, Toronto, ON M5G 2 N2 Canada
| | - Joanne Kappel
- Department of Medicine, Division of Nephrology, University of Saskatchewan, Saskatoon, SK Canada
| | - Louise M Moist
- Department of Medicine, Division of Nephrology, Western University, London, ON Canada
| | - Scott W Klarenbach
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, AB Canada
| | - Susan M Samuel
- Department of Pediatrics, Division of Nephrology, University of Calgary, Calgary, AB Canada
| | - Lianne G Singer
- Multi-Organ Transplant Program, University Health Network, Toronto, ON Canada ; Department of Medicine, Division of Respirology, University of Toronto, Toronto, ON Canada
| | - Daniel H Kim
- Department of Medicine, Division of Cardiology, University of Alberta, Edmonton, AB Canada
| | - Kimberly Young
- Donation and Transplantation, Canadian Blood Services, Ottawa, ON Canada
| | - Greg Webster
- Canadian Institute for Health Information, Toronto, ON Canada
| | - Juliana Wu
- Canadian Institute for Health Information, Toronto, ON Canada
| | - Frank Ivis
- Canadian Institute for Health Information, Toronto, ON Canada
| | - Eric de Sa
- Canadian Institute for Health Information, Toronto, ON Canada
| | - John S Gill
- Department of Medicine, Division of Nephrology, University of British Columbia, Vancouver, BC Canada
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43
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Sis B, Bagnasco SM, Cornell LD, Randhawa P, Haas M, Lategan B, Magil AB, Herzenberg AM, Gibson IW, Kuperman M, Sasaki K, Kraus ES. Isolated endarteritis and kidney transplant survival: a multicenter collaborative study. J Am Soc Nephrol 2014; 26:1216-27. [PMID: 25381427 DOI: 10.1681/asn.2014020157] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 08/04/2014] [Indexed: 11/03/2022] Open
Abstract
Isolated endarteritis of kidney transplants is increasingly recognized. Notably, microarray studies revealed absence of immunologic signatures of rejection in most isolated endarteritis biopsy samples. We investigated if isolated endarteritis responds to rejection treatment and affects kidney transplant survival. We retrospectively enrolled recipients of kidney transplant who underwent biopsies between 1999 and 2011 at seven American and Canadian centers. Exclusion criteria were recipients were blood group-incompatible or crossmatch-positive or had C4d-positive biopsy samples. After biopsy confirmation, patients were divided into three groups: isolated endarteritis (n=103), positive controls (type I acute T cell-mediated rejection with endarteritis; n=101), and negative controls (no diagnostic rejection; n=103). Primary end points were improved kidney function after rejection treatment and transplant failure. Mean decrease in serum creatinine from biopsy to 1 month after rejection treatment was 132.6 µmol/L (95% confidence interval [95% CI], 78.7 to 186.5) in patients with isolated endarteritis, 96.4 µmol/L (95% CI, 48.6 to 143.2) in positive controls (P=0.32), and 18.6 µmol/L (95% CI, 1.8 to 35.4) in untreated negative controls (P<0.001). Functional improvement after rejection treatment occurred in 80% of patients with isolated endarteritis and 81% of positive controls (P=0.72). Over the median 3.2-year follow-up period, kidney transplant survival rates were 79% in patients with isolated endarteritis, 79% in positive controls, and 91% in negative controls (P=0.01). In multivariate analysis, isolated endarteritis was associated with an adjusted 3.51-fold (95% CI, 1.16 to 10.67; P=0.03) risk for transplant failure. These data indicate that isolated endarteritis is an independent risk factor for kidney transplant failure.
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Affiliation(s)
- Banu Sis
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada;
| | | | - Lynn D Cornell
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Parmjeet Randhawa
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Mark Haas
- Department of Pathology and Laboratory Medicine, Cedars Sinai Medical Center, Los Angeles, California
| | - Belinda Lategan
- Department of Pathology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alex B Magil
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada; and
| | - Andrew M Herzenberg
- Department of Pathology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Ian W Gibson
- Department of Pathology, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Kotaro Sasaki
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Edward S Kraus
- Department of Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Mercado-Martínez FJ, Hernández-Ibarra E, Ascencio-Mera CD, Díaz-Medina BA, Padilla-Altamira C, Kierans C. Viviendo con trasplante renal, sin protección social en salud: ¿Qué dicen los enfermos sobre las dificultades económicas que enfrentan y sus efectos? CAD SAUDE PUBLICA 2014; 30:2092-100. [DOI: 10.1590/0102-311x00150713] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Accepted: 03/07/2014] [Indexed: 11/21/2022] Open
Abstract
El trasplante es el mejor tratamiento para la insuficiencia renal, de acuerdo con la biomedicina; sin embargo, es una tecnología cara. Este artículo examina las dificultades económicas y sus efectos en personas con trasplante renal, pero sin protección social en salud. Para el estudio se desarrolló una investigación cualitativa en México. Participaron 21 pacientes trasplantados; se aplicaron entrevistas semiestructuradas, y se realizó un análisis de contenido. Los resultados muestran que las personas enfermas enfrentan dificultades económicas, debido a los costes de las terapias renales, particularmente, de las medicinas. Todo ello tiene efectos negativos: las personas con pocos recursos dejan el tratamiento con medicamentos, abandonan el protocolo, no asisten a las consultas médicas y disminuyen los gastos domésticos, incluyendo el de alimentación; además de suponer una merma en los ingresos familiares. En conclusión, el trasplante renal empobrece a las personas enfermas sin protección social en salud; es urgente la implementación de un sistema de protección social para esta población.
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45
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Tennankore KK, Kim SJ, Baer HJ, Chan CT. Survival and hospitalization for intensive home hemodialysis compared with kidney transplantation. J Am Soc Nephrol 2014; 25:2113-20. [PMID: 24854268 PMCID: PMC4147990 DOI: 10.1681/asn.2013111180] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Accepted: 01/10/2014] [Indexed: 12/25/2022] Open
Abstract
Canadian patients receiving intensive home hemodialysis (IHHD; ≥16 hours per week) have survival comparable to that of deceased donor kidney transplant recipients in the United States, but a comparison with Canadian kidney transplant recipients has not been conducted. We conducted a retrospective cohort study of consecutive, adult IHHD patients and kidney transplant recipients between 2000 and 2011 at a large Canadian tertiary care center. The primary outcome was time-to-treatment failure or death for IHHD patients compared with expanded criteria, standard criteria, and living donor recipients, and secondary outcomes included hospitalization rate. Treatment failure was defined as a permanent switch to an alternative dialysis modality for IHHD patients, and graft failure for transplant recipients. The cohort comprised 173 IHHD patients and 202 expanded criteria, 642 standard criteria, and 673 living donor recipients. There were 285 events in the primary analysis. Transplant recipients had a reduced risk of treatment failure/death compared with IHHD patients, with relative hazards of 0.45 (95% confidence interval [95% CI], 0.31 to 0.67) for living donor recipients, 0.39 (95% CI, 0.26 to 0.59) for standard criteria donor recipients, and 0.42 (95% CI, 0.26 to 0.67) for expanded criteria donor recipients. IHHD patients had a lower hospitalization rate in the first year of treatment compared with standard criteria donor recipients and in the first 3 months of treatment compared with living donor and expanded criteria donor recipients. In this cohort, kidney transplantation was associated with superior treatment and patient survival, but higher early rates of hospitalization, compared with IHHD.
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Affiliation(s)
| | - S Joseph Kim
- Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada; Division of Nephrology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Heather J Baer
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; and Department of Epidemiology, Harvard School of Public Health, Boston Massachusetts
| | - Christopher T Chan
- Division of Nephrology, University Health Network, University of Toronto, Toronto, Ontario, Canada
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46
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Abstract
One in 10 Americans suffers from chronic kidney disease, and close to 90,000 people die each year from causes related to kidney failure. Patients with end-stage renal disease are faced with two options: hemodialysis or transplantation. Unfortunately, the transplantation option is limited because of the shortage of donor organs and the need for immunosuppression. Bioengineered kidney grafts theoretically present a novel solution to both problems. Herein, we discuss the history of bioengineering organs, the current status of bioengineered kidneys, considerations for the future of the field, and challenges to clinical translation. We hope that by integrating principles of tissue engineering, and stem cell and developmental biology, bioengineered kidney grafts will advance the field of regenerative medicine while meeting a critical clinical need.
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Affiliation(s)
- Maria Lucia L Madariaga
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Harvard Stem Cell Institute, Boston, MA; Center for Regenerative Medicine, Massachusetts General Hospital, Boston, MA
| | - Harald C Ott
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Harvard Stem Cell Institute, Boston, MA; Center for Regenerative Medicine, Massachusetts General Hospital, Boston, MA.
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47
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Popoola J, Greene H, Kyegombe M, MacPhee IA. Patient involvement in selection of immunosuppressive regimen following transplantation. Patient Prefer Adherence 2014; 8:1705-12. [PMID: 25525347 PMCID: PMC4270302 DOI: 10.2147/ppa.s38987] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Transplantation has made a considerable difference to the lives of many patients. However, feedback from patients indicates that although having a transplant is a hugely positive experience, having to take medications indefinitely is one of the biggest challenges. An ideal scenario would be no medications following a transplant. A compromise would be a minimal number of medications, with minimal restrictions and as simple a regimen as possible. Although there is considerable research going into fine-tuning the management of the immune response to a transplant, to date there is no universal regimen that enables patients to remain free of immunosuppressant medications, making adherence paramount to maintain long-term allograft survival. This paper reviews the available immunosuppressant regimens and factors influencing choice from both the clinician's and the patient's perspective. Factors influencing the decision-making process, such as quality of life for patients, their satisfaction, acceptability, and adherence uptake are reviewed. We conclude with a further assessment of patient choice as a factor in regimen selection, its impact on adherence, and its implications.
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Affiliation(s)
- Joyce Popoola
- Department of Nephrology and Transplantation, London, UK
- St George’s University of London, London, UK
- Correspondence: Joyce Popoola, Department of Nephrology and Transplantation, St George’s Healthcare NHS Trust, Blackshaw Road, London, SW17 0QT, UK, Tel +208 725 2705, Fax +208 725 2068, Email
| | - Helen Greene
- Department of Pharmacy, St George’s Healthcare NHS Trust, London, UK
| | - Margaret Kyegombe
- Department of Pharmacy, St George’s Healthcare NHS Trust, London, UK
| | - Iain A MacPhee
- Department of Nephrology and Transplantation, London, UK
- St George’s University of London, London, UK
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48
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Pongpirul K, Pongpirul WA, Avihingsanon Y, Noppakun K, Ingsathit A, Pongskul C, Premasthian N, Lumpaopong A, Vareesangthip K, Sumethkul V. Potential impact of Thai Kidney Transplant program on immunosuppressive utilization: an analysis of the national transplant registry. Transplant Proc 2014; 46:422-4. [PMID: 24655979 DOI: 10.1016/j.transproceed.2013.11.109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Accepted: 11/15/2013] [Indexed: 02/05/2023]
Abstract
BACKGROUND The Thai Kidney Transplant (TKT) program was launched in October 2008 to promote transplantation among previously disadvantaged populations, using fixed-rate provider payment. This study investigated if the introduction of this program could alter the natural practice trends of immunosuppressive drug use. METHODS Data from the Thai Transplantation Registry were analyzed. The change in trend of immunosuppressive use was assessed using the multivariate adaptive regression splines (MARS) technique. RESULTS During 1987-2012, 3975 kidney transplantations were done. The average age of patients was 42 years and 62% were male. Chronic glomerulonephritis accounted for one third of those with known causes of end-stage renal disease (ESRD). Eighty-six percent were on hemodialysis before transplantation. Prednisolone was used in 95.87% of all transplant recipients, whereas calcineurin inhibitors (CNIs), mycophenolates (MPAs), azathioprine (AZA), and mammalian target of rapamycin inhibitors (mTORis) were used in 95.67%, 64.22%, 12.25%, and 2.31%, respectively. Overall use after 2008 was decreased for AZA (18.16% to 3.40%) and mTORis (2.86% to 1.5%) but increased for MPAs (50.80% to 84.34%), CNIs (95.43% to 96.04%), and prednisolone (95.60% to 96.29%), as compared with before the program inception. The slopes of use trends of AZA, MPAs, and CNIs did not significantly marginally differ from their natural trends before the program inception (P = .496, .108, and .741, respectively). However, the natural increasing use trend of mTORis significantly changed to a decreasing pattern after the introduction of the TKT program (P = .018). CONCLUSION Fixed-rate provider payment might interfere with the natural practice trends of immunosuppressive drug use.
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Affiliation(s)
- K Pongpirul
- Department of Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University, Patumwan, Bangkok, Thailand; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Thailand Research Center for Health Services System, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
| | - W A Pongpirul
- Department of Internal Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Y Avihingsanon
- Department of Internal Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Organ Transplantation Excellence Center, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - K Noppakun
- Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - A Ingsathit
- Department of Internal Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - C Pongskul
- Department of Internal Medicine, Srinakarind Hospital, Khon Kaen University, Khon Kaen, Thailand
| | - N Premasthian
- Department of Internal Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - A Lumpaopong
- Department of Pediatrics, Phramongkutklao Hospital, Bangkok, Thailand
| | - K Vareesangthip
- Department of Internal Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - V Sumethkul
- Department of Internal Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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49
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Begaj I, Khosla S, Ray D, Sharif A. Socioeconomic deprivation is independently associated with mortality post kidney transplantation. Kidney Int 2013; 84:803-9. [DOI: 10.1038/ki.2013.176] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2012] [Revised: 02/21/2013] [Accepted: 03/01/2013] [Indexed: 11/09/2022]
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50
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Tanriover B, Stone PW, Mohan S, Cohen DJ, Gaston RS. Future of Medicare immunosuppressive drug coverage for kidney transplant recipients in the United States. Clin J Am Soc Nephrol 2013; 8:1258-66. [PMID: 23559679 DOI: 10.2215/cjn.09440912] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Kidney transplantation is the preferred treatment for patients with ESRD. It improves the quality of life in recipients, increases patient survival, and is also substantially less costly than maintenance dialysis. Long-term transplant success requires immunosuppressant drug therapy for the life of the allograft. Under current law, Medicare coverage for most recipients (except for those recipients over 65 years of age or with nonkidney-related disabilities) lasts only 3 years, leaving many recipients unable to afford these medications. Lack of drug therapy often leads to allograft rejection, resulting in premature graft failure, return to dialysis, or death. This article reviews the current policy for Medicare immunosuppressive drug coverage and analyzes the potential impact of pending legislative proposals H.R. 2969 and S. 1454 and the Patient Protection and Affordable Care Act.
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Affiliation(s)
- Bekir Tanriover
- Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York 10032, USA.
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