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Cooper TE, Dalton A, Kieu A, Gately R, Bourke MJ, Craig JC, Khalid R, Lim WH, Scholes-Robertson N, Teixeira-Pinto A, Jaure A, Wong G, Howell M. Patient Preferences for the Management of Gastrointestinal Symptoms in Kidney Transplantation: a Discrete Choice Experiment. Kidney Int Rep 2023; 8:1978-1988. [PMID: 37850002 PMCID: PMC10577360 DOI: 10.1016/j.ekir.2023.07.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 07/13/2023] [Accepted: 07/31/2023] [Indexed: 10/19/2023] Open
Abstract
Introduction Gastrointestinal (GI) symptoms in kidney transplant are common and debilitating. We aimed to ascertain patients' preferences for GI symptom management options to help future interventions align with treatment priorities. Methods A discrete choice experiment was conducted with kidney transplant recipients in 3 Australian nephrology units. A multinomial logit model was used to quantify the preferences and trade-offs between 5 characteristics: cost, formulation, symptom burden, dietary changes, and medication quantities. Results Seventy patients participated (mean age ± SD: 47 ± 15 years, 56% female), 57% had GI symptoms. Patients preferred interventions that will achieve complete resolution of GI symptoms compared to no improvement (odds ratio [95% confidence interval]: 15.3 [1.80, 129.50]), were delivered as a tablet rather than a sachet (1.6 [1.27, 2.08]), retained their current diet compared to eliminating food groups (6.0 [2.19, 16.27]), reduced medication burden (1.4 [1.06, 1.79]), and had lower costs (0.98 [0.96, 1.00]). Participants would be willing to pay AUD$142.20 [$83.90, $200.40] monthly to achieve complete resolution of GI symptoms or AUD$100.90 [$9.60, $192.10] to have moderate improvement in symptoms. Conclusions Interventions that are highly effective in relieving all GI symptoms without the need for substantive dietary changes, and in tablet form, are most preferred by kidney transplant recipients.
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Affiliation(s)
- Tess E. Cooper
- Cochrane Kidney and Transplant, The Children's Hospital at Westmead, Australia
- Sydney School of Public Health, The University of Sydney, Australia
- Center for Kidney Research, The Children’s Hospital at Westmead, Australia
| | - Amy Dalton
- Sydney School of Public Health, The University of Sydney, Australia
- Center for Kidney Research, The Children’s Hospital at Westmead, Australia
| | - Anh Kieu
- Cochrane Kidney and Transplant, The Children's Hospital at Westmead, Australia
- Center for Kidney Research, The Children’s Hospital at Westmead, Australia
| | - Ryan Gately
- Princess Alexandra Hospital, Australia
- School of Medicine, The University of Queensland, Australia
| | - Michael J. Bourke
- Westmead Hospital, Australia
- Sydney Medical School, The University of Sydney, Australia
| | - Jonathan C. Craig
- Cochrane Kidney and Transplant, The Children's Hospital at Westmead, Australia
- College of Medicine and Public Health, Flinders University, Australia
| | - Rabia Khalid
- Sydney School of Public Health, The University of Sydney, Australia
- Center for Kidney Research, The Children’s Hospital at Westmead, Australia
| | - Wai H. Lim
- Sir Charles Gairdner Hospital, Australia
- School of Medicine, University of Western Australia, Australia
| | - Nicole Scholes-Robertson
- Cochrane Kidney and Transplant, The Children's Hospital at Westmead, Australia
- Sydney School of Public Health, The University of Sydney, Australia
- Center for Kidney Research, The Children’s Hospital at Westmead, Australia
| | - Armando Teixeira-Pinto
- Sydney School of Public Health, The University of Sydney, Australia
- Center for Kidney Research, The Children’s Hospital at Westmead, Australia
| | - Allison Jaure
- Sydney School of Public Health, The University of Sydney, Australia
- Center for Kidney Research, The Children’s Hospital at Westmead, Australia
| | - Germaine Wong
- Sydney School of Public Health, The University of Sydney, Australia
- Center for Kidney Research, The Children’s Hospital at Westmead, Australia
- Westmead Hospital, Australia
| | - Martin Howell
- Sydney School of Public Health, The University of Sydney, Australia
- Center for Kidney Research, The Children’s Hospital at Westmead, Australia
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Tong A, Oberbauer R, Bellini MI, Budde K, Caskey FJ, Dobbels F, Pengel L, Rostaing L, Schneeberger S, Naesens M. Patient-Reported Outcomes as Endpoints in Clinical Trials of Kidney Transplantation Interventions. Transpl Int 2022; 35:10134. [PMID: 35669971 PMCID: PMC9163311 DOI: 10.3389/ti.2022.10134] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 02/17/2022] [Indexed: 12/13/2022]
Abstract
Patient-reported outcomes (PROs) that assess individuals' perceptions of life participation, medication adherence, disease symptoms, and therapy side effects are extremely relevant in the context of kidney transplantation. All PROs are potentially suitable as primary or secondary endpoints in interventional trials that aim to improve outcomes for transplant recipients. Using PRO measures (PROMs) in clinical trials facilitates assessment of the patient's perspective of their health, but few measures have been developed and evaluated in kidney transplant recipients; robust methodologies, which use validated instruments and established frameworks for reporting, are essential. Establishing a core PROM for life participation in kidney transplant recipients is a critically important need, which is being developed and validated by the Standardized Outcomes in Nephrology (SONG)-Tx Initiative. Measures involving electronic medication packaging and smart technologies are gaining traction for monitoring adherence, and could provide more robust information than questionnaires, interviews, and scales. This article summarizes information on PROs and PROMs that was included in a Broad Scientific Advice request on clinical trial design and endpoints in kidney transplantation. This request was submitted to the European Medicines Agency (EMA) by the European Society for Organ Transplantation in 2016. Following modifications, the EMA provided its recommendations in late 2020.
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Affiliation(s)
- Allison Tong
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - Rainer Oberbauer
- Department of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | | | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Fergus J. Caskey
- Department of Population Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Fabienne Dobbels
- Department of Public Health and Primary Care, Academic Center for Nursing and Midwifery, KU Leuven, Leuven, Belgium
| | - Liset Pengel
- Centre for Evidence in Transplantation, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Lionel Rostaing
- Department of Nephrology, Dialysis and Transplantation, Toulouse University Hospital, Toulouse, France
| | - Stefan Schneeberger
- Department of General, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
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Małyszko J, Bamias A, Danesh FR, Dębska-Ślizień A, Gallieni M, Gertz MA, Kielstein JT, Tesarova P, Wong G, Cheung M, Wheeler DC, Winkelmayer WC, Porta C. KDIGO Controversies Conference on onco-nephrology: kidney disease in hematological malignancies and the burden of cancer after kidney transplantation. Kidney Int 2020; 98:1407-1418. [PMID: 33276867 DOI: 10.1016/j.kint.2020.07.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 06/02/2020] [Accepted: 07/02/2020] [Indexed: 01/01/2023]
Abstract
The bidirectional relationship between cancer and chronic kidney disease (CKD) is complex. Patients with cancer, particularly those with hematological malignancies such as multiple myeloma and lymphoma, are at increased risk of developing acute kidney injury and CKD. On the other hand, emerging evidence from large observational registry analyses have consistently shown that cancer risk is increased by at least 2- to 3-fold in kidney transplant recipients, and the observed increased risk occurs not only in those who have received kidney transplants but also in those on dialysis and with mild- to moderate-stage CKD. The interactions between cancer and CKD have raised major therapeutic and clinical challenges in the management of these patients. Given the magnitude of the problem and uncertainties, and current controversies within the existing evidence, Kidney Disease: Improving Global Outcomes (KDIGO) assembled a global panel of multidisciplinary clinical and scientific expertise for a controversies conference on onco-nephrology to identify key management issues in nephrology relevant to patients with malignancy. This report covers the discussed controversies in kidney disease in hematological malignancies, as well as cancer after kidney transplantation. An overview of future research priorities is also discussed.
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Affiliation(s)
- Jolanta Małyszko
- Department of Nephrology, Dialysis, and Internal Medicine, Medical University of Warsaw, Poland
| | - Aristotelis Bamias
- Second Propaedeutic Department of Internal Medicine, National and Kapodistrian University of Athens, Greece
| | - Farhad R Danesh
- Section of Nephrology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Alicja Dębska-Ślizień
- Clinical Department of Nephrology, Transplantology and Internal Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - Maurizio Gallieni
- Nephrology and Dialysis Unit, Luigi Sacco Department of Biomedical and Clinical Sciences, Università di Milano, Milan, Italy
| | - Morie A Gertz
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jan T Kielstein
- Medical Clinic V, Nephrology, Rheumatology, Blood Purification, Academic Teaching Hospital Braunschweig, Braunschweig, Germany
| | - Petra Tesarova
- Department of Oncology, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Germaine Wong
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, New South Wales, Australia; Sydney School of Public Health, University of Sydney, New South Wales, Australia
| | | | - David C Wheeler
- Department of Renal Medicine, University College London, London, UK; George Institute for Global Health, Sydney, Australia
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Camillo Porta
- Department of Internal Medicine and Therapeutics, University of Pavia and Division of Translational Oncology, IRCCS Istituti Clinici Scientifici Maugeri, Pavia, Italy.
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Establishing a Core Outcome Measure for Graft Health: A Standardized Outcomes in Nephrology-Kidney Transplantation (SONG-Tx) Consensus Workshop Report. Transplantation 2019; 102:1358-1366. [PMID: 29470347 DOI: 10.1097/tp.0000000000002125] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Graft loss, a critically important outcome for transplant recipients, is variably defined and measured, and incompletely reported in trials. We convened a consensus workshop on establishing a core outcome measure for graft loss for all trials in kidney transplantation. METHODS Twenty-five kidney transplant recipients/caregivers and 33 health professionals from 8 countries participated. Transcripts were analyzed thematically. RESULTS Five themes were identified. "Graft loss as a continuum" conceptualizes graft loss as a process, but requiring an endpoint defined as a discrete event. In "defining an event with precision and accuracy," loss of graft function requiring chronic dialysis (minimum, 90 days) provided an objective and practical definition; retransplant would capture preemptive transplantation; relisting was readily measured but would overestimate graft loss; and allograft nephrectomy was redundant in being preceded by dialysis. However, the thresholds for renal replacement therapy varied. Conservative management was regarded as too ambiguous and complex to use routinely. "Distinguishing death-censored graft loss" would ensure clarity and meaningfulness in interpreting results. "Consistent reporting for decision making" by specifying time points and metrics (ie time to event) was suggested. "Ease of ascertainment and data collection" of the outcome from registries could support use of registry data to efficiently extend follow-up of trial participants. CONCLUSIONS A practical and meaningful core outcome measure for graft loss may be defined as chronic dialysis or retransplant, and distinguished from loss due to death. Consistent reporting of graft loss using standardized metrics and time points may improve the contribution of trials to decision making in kidney transplantation.
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Abstract
Decision making in transplantation is complex, dynamic, and often made under the context of uncertainties. In the case of diagnostic uncertainties, symptoms can be indistinct, with overlap between many different conditions. Even if the correct diagnoses are known, treatment strategies for the same condition may vary and are largely dependent on clinicians' preference and personal experiences. Systematic reviews and meta-analyses challenge the conventional role of the experts and their perceptions and rely, instead, on the best available evidence to guide clinical decision making. Through careful searching and closely examining, appraising, and synthesizing all available evidence, systematic reviews and meta-analyses provide the necessary and relevant information to better inform healthcare management and policy making by highlighting evidence that is pertinent to decisions. This commentary provides an overview of the concepts and methods used in systematic review, highlighting the potential capability of these methods in transplantation and how they may facilitate clinical decision making in transplantation.
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Bafeta A, Koh M, Riveros C, Ravaud P. Harms Reporting in Randomized Controlled Trials of Interventions Aimed at Modifying Microbiota: A Systematic Review. Ann Intern Med 2018; 169:240-247. [PMID: 30014150 DOI: 10.7326/m18-0343] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Probiotics, prebiotics, and synbiotics are used increasingly, although the safety and potential harms of these interventions are poorly understood. PURPOSE To examine how harms-related information is reported in publications of randomized controlled trials (RCTs) of probiotics, prebiotics, and synbiotics. DATA SOURCES Cochrane Central Register of Controlled Trials, PubMed, EMBASE, and Web of Science (without language restrictions) from 1 January 2015 to 20 March 2018. STUDY SELECTION RCTs assessing the safety or efficacy of at least 1 intervention involving probiotics, prebiotics, or synbiotics alone or in combination with another intervention compared with any control (such as a placebo or an antibiotic) for any clinical condition. DATA EXTRACTION 4 reviewers independently assessed study characteristics, the reporting of harms, and the presentation of safety results. DATA SYNTHESIS Of 384 trials conducted in healthy volunteers (n = 136) or patients with any of several medical conditions (n = 248), 339 (88%) were published in specialty journals. Trials most often evaluated probiotics (n = 265 [69%]). Studies in persons with medical conditions enrolled outpatients (n = 195) and high-risk patients (n = 53). No harms-related data were reported for 106 trials (28%), safety results were not reported for 142 (37%), and the number of serious adverse events (SAEs) per study group was not given for 309 (80%). Of 242 studies mentioning harms-related results, 37% (n = 89) used only generic statements to describe AEs and 16% (n = 38) used inadequate metrics. Overall, 375 trials (98%) did not give a definition for AEs or SAEs, the number of participant withdrawals due to harms, or the number of AEs and SAEs per study group with denominators. LIMITATION Journal publication processes may have affected the completeness of reporting; only English-language publications were examined. CONCLUSION Harms reporting in published reports of RCTs assessing probiotics, prebiotics, and synbiotics often is lacking or inadequate. We cannot broadly conclude that these interventions are safe without reporting safety data. PRIMARY FUNDING SOURCE No specific funding.
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Affiliation(s)
- Aïda Bafeta
- INSERM U1153 and Université Paris Descartes-Sorbonne Paris Cité, Paris, France (A.B., C.R.)
| | - Mitsuki Koh
- Columbia University, New York, New York (M.K.)
| | - Carolina Riveros
- INSERM U1153 and Université Paris Descartes-Sorbonne Paris Cité, Paris, France (A.B., C.R.)
| | - Philippe Ravaud
- INSERM U1153, Université Paris Descartes-Sorbonne Paris Cité, and French Cochrane Centre, Paris, France, and Columbia University, New York, New York (P.R.)
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