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Smith JD, Agrawal A, Wicklund C, Duquette D, Friedewald J, Rasmussen LV, Gacki-Smith J, Tandon SD, Muhammad LN, Yancy CW, Dong S, Cooper M, Gilbert A, Shetty A, Gordon EJ. Implementation of a culturally competent APOL1 genetic testing programme into living donor evaluation: A two-site, non-randomised, pre-post trial design. BMJ Open 2023; 13:e067657. [PMID: 37188469 PMCID: PMC10186444 DOI: 10.1136/bmjopen-2022-067657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 04/14/2023] [Indexed: 05/17/2023] Open
Abstract
INTRODUCTION While living donor (LD) kidney transplantation is the optimal treatment for patients with kidney failure, LDs assume a higher risk of future kidney failure themselves. LDs of African ancestry have an even greater risk of kidney failure post-donation than White LDs. Because evidence suggests that Apolipoprotein L1 (APOL1) risk variants contribute to this greater risk, transplant nephrologists are increasingly using APOL1 genetic testing to evaluate LD candidates of African ancestry. However, nephrologists do not consistently perform genetic counselling with LD candidates about APOL1 due to a lack of knowledge and skill in counselling. Without proper counselling, APOL1 testing will magnify LD candidates' decisional conflict about donating, jeopardising their informed consent. Given cultural concerns about genetic testing among people of African ancestry, protecting LD candidates' safety is essential to improve informed decisions about donating. Clinical 'chatbots', mobile apps that provide genetic information to patients, can improve informed treatment decisions. No chatbot on APOL1 is available and no nephrologist training programmes are available to provide culturally competent counselling to LDs about APOL1. Given the shortage of genetic counsellors, increasing nephrologists' genetic literacy is critical to integrating genetic testing into practice. METHODS AND ANALYSIS Using a non-randomised, pre-post trial design in two transplant centres (Chicago, IL, and Washington, DC), we will evaluate the effectiveness of culturally competent APOL1 testing, chatbot and counselling on LD candidates' decisional conflict about donating, preparedness for decision-making, willingness to donate and satisfaction with informed consent and longitudinally evaluate the implementation of this intervention into clinical practice using the Reach, Effectiveness, Adoption, Implementation and Maintenance framework. ETHICS AND DISSEMINATION This study will create a model for APOL1 testing of LDs of African ancestry, which can be implemented nationally via implementation science approaches. APOL1 will serve as a model for integrating culturally competent genetic testing into transplant and other practices to improve informed consent. This study involves human participants and was approved by Northwestern University IRB (STU00214038). Participants gave informed consent to participate in the study before taking part. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04910867. Registered 8 May 2021, https://register. CLINICALTRIALS gov/prs/app/action/SelectProtocol?sid=S000AWZ6&selectaction=Edit&uid=U0001PPF&ts=7&cx=-8jv7m2 ClinicalTrials.gov Identifier: NCT04999436. Registered 5 November 2021, https://register. CLINICALTRIALS gov/prs/app/action/SelectProtocol?sid=S000AYWW&selectaction=Edit&uid=U0001PPF&ts=11&cx=9tny7v.
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Affiliation(s)
- Justin D Smith
- Department of Population Health Sciences, Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, Utah, USA
- Departments of Psychiatry and Behavioral Sciences and Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Akansha Agrawal
- Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Catherine Wicklund
- Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Debra Duquette
- Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - John Friedewald
- Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Luke V Rasmussen
- Division of Health and Biomedical Informatics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jessica Gacki-Smith
- Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - S Darius Tandon
- Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Lutfiyya N Muhammad
- Department of Preventive Medicine-Division of Biostatistics, Northwestern University, Chicago, Illinois, USA
| | - Clyde W Yancy
- Department of Medicine-Division of Cardiology, Northwestern University, Evanston, Illinois, USA
| | - Siyuan Dong
- Department of Preventive Medicine-Division of Biostatistics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Matthew Cooper
- Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Alexander Gilbert
- Medicine, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Aneesha Shetty
- Medicine, The University of Arizona College of Medicine Tucson, Tucson, Arizona, USA
| | - Elisa J Gordon
- Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Influence of Donor Race and Donor-recipient Race-matching on Pediatric Kidney Transplant Outcomes. Transplant Direct 2022; 8:e1324. [PMID: 35557992 PMCID: PMC9088235 DOI: 10.1097/txd.0000000000001324] [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: 03/02/2022] [Accepted: 03/04/2022] [Indexed: 11/26/2022] Open
Abstract
Existing literature has demonstrated the significant relationship between race and kidney transplant outcomes; however, there are conflicting and limited data on the influence of donor race or donor-recipient race-matching on pediatric kidney transplant outcomes.
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Soraru J, Chakera A, Isbel N, Mallawaarachichi A, Rogers N, Trnka P, Patel C, Mallett A. The evolving role of diagnostic genomics in kidney transplantation. Kidney Int Rep 2022; 7:1758-1771. [PMID: 35967121 PMCID: PMC9366366 DOI: 10.1016/j.ekir.2022.05.019] [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: 04/05/2022] [Revised: 05/11/2022] [Accepted: 05/16/2022] [Indexed: 11/06/2022] Open
Abstract
Monogenic forms of heritable kidney disease account for a significant proportion of chronic kidney disease (CKD) across both pediatric and adult patient populations and up to 11% of patients under 40 years reaching end-stage kidney failure (KF) and awaiting kidney transplant. Diagnostic genomics in the field of nephrology is ever evolving and now plays an important role in assessment and management of kidney transplant recipients and their related donor pairs. Genomic testing can help identify the cause of KF in kidney transplant recipients and assist in prognostication around graft survival and rate of recurrence of primary kidney disease. If a gene variant has been identified in the recipient, at-risk related donors can be assessed for the same and excluded if affected. This paper aims to address the indications for genomic testing in the context for kidney transplantation, the technologies available for testing, the conditions and groups in which testing should be most often considered, and the role for the renal genetics multidisciplinary team in this process.
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Harris DD, Fleishman A, Pavlakis M, Pollak MR, Baliga PK, Rohan V, Kayler LK, Rodrigue JR. Apolipoprotein L1 Opinions of African American Living Kidney Donors, Kidney Transplant Patients, and Nonpatients. J Surg Res 2022; 277:116-124. [PMID: 35489216 DOI: 10.1016/j.jss.2022.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 02/03/2022] [Accepted: 04/06/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The discovery of apolipoprotein L1 (ApoL1) has raised important ethical and clinical questions about genetic testing in the context of living and deceased kidney donation. Largely missing from this discussion are the perspectives of those African Americans (AA) most likely to be impacted by ApoL1 testing. METHODS We surveyed 331 AA potential and former living kidney donors (LKDs), kidney transplant candidates and recipients, and nonpatients at three United States transplant programs about their ApoL1 testing attitudes. RESULTS Overall, 72% felt that transplant programs should offer ApoL1 testing to AA potential LKDs. If a potential LKD has the high-risk genotype, 79% felt that the LKD should be allowed to make their own donation decision or participate in shared decision-making with transplant doctors. More than half of the potential LKDs (58%) would undergo ApoL1 testing and 81% of former LKDs would take the test now if offered. Most transplant candidates expressed a low likelihood of accepting a kidney from a LKD (79%) or a deceased donor (67%) with the high-risk genotype. CONCLUSIONS There is strong support among LKDs and transplant patients for ApoL1 testing when evaluating potential kidney donors of African ancestry. Inclusion of AA stakeholders in developing guidelines and educational programs for ApoL1 testing is critical.
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Affiliation(s)
- Dwight D Harris
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Aaron Fleishman
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Martha Pavlakis
- Department of Surgery, Harvard Medical School, Boston, Massachusetts; Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Martin R Pollak
- Department of Surgery, Harvard Medical School, Boston, Massachusetts; Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Prabhakar K Baliga
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Vinayak Rohan
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Liise K Kayler
- Department of Surgery, University at Buffalo (SUNY) Jacobs School of Medicine & Biomedical Sciences and Erie County Medical Center, Buffalo, New York
| | - James R Rodrigue
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts; Department of Surgery, Medical University of South Carolina, Charleston, South Carolina.
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Berrigan M, Austrie J, Fleishman A, Tercyak KP, Pollak MR, Pavlakis M, Rohan V, Baliga PK, Kayler LK, Feeley TH, Rodrigue JR. Opinions of African American adults about the use of apolipoprotein L1 (ApoL1) genetic testing in living kidney donation and transplantation. Am J Transplant 2021; 21:1197-1205. [PMID: 32659871 PMCID: PMC7854990 DOI: 10.1111/ajt.16206] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/23/2020] [Accepted: 07/07/2020] [Indexed: 02/06/2023]
Abstract
Apolipoprotein L1 (ApoL1) predictive genetic testing for kidney disease, and its emerging role in transplantation, remains controversial as it may exacerbate underlying disparities among African Americans (AAs) at increased risk. We conducted an online simulation among AAs (N = 585) about interest in ApoL1 testing and its cofactors, under 2 scenarios: as a potential living donor (PLD), and as a patient awaiting transplantation. Most respondents (61%) expressed high interest in genetic testing as a PLD: age ≥35 years (adjusted odds ratio [aOR], 1.75; 95% confidence interval [CI], 1.18, 2.60, P = .01), AA identity (aOR, 1.67; 95% CI, 1.02, 2.72, P = .04), perceived kidney disease risk following donation (aOR, 1.68; 95% CI, 1.03, 2.73, P = .03), interest in genetics (aOR, 2.89; 95% CI, 1.95, 4.29, P = .001), and genetics self-efficacy (aOR, 2.38; 95% CI, 1.54, 3.67, P = .001) were positively associated with ApoL1 test interest. If awaiting transplantation, most (89%) believed that ApoL1 testing should be done on AA deceased donors, and older age (aOR, 1.85; 95% CI, 1.03, 3.32, P = .04) and greater interest in genetics (aOR, 2.61; 95% CI, 1.41, 4.81, P = .002) were associated with interest in testing deceased donors. Findings highlight strong support for ApoL1 testing in AAs and the need to examine such opinions among PLDs and transplant patients to enhance patient education efforts.
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Affiliation(s)
- Margaret Berrigan
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Jasmine Austrie
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Aaron Fleishman
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Kenneth P Tercyak
- Departments of Oncology and Pediatrics, Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Martin R Pollak
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Martha Pavlakis
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Vinayak Rohan
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Prabhakar K Baliga
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Liise K Kayler
- Department of Surgery, University at Buffalo (SUNY) Jacobs School of Medicine & Biomedical Sciences and Erie County Medical Center, Buffalo, New York, USA
| | - Thomas H Feeley
- Department of Communication, University at Buffalo (SUNY), Buffalo, New York, USA
| | - James R Rodrigue
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Abstract
PURPOSE OF REVIEW To summarize the current state of evidence regarding the role of apolipoprotein L1 (APOL1) genotyping in evaluating donors for kidney transplantation. RECENT FINDINGS African ancestry is associated with an increased risk of kidney failure following living donation. Moreover, kidney transplants from African ancestry deceased donors have an increased risk of graft failure. Preliminary evidence suggests that APOL1 genotype may mediate at least a portion of this racial variation, with high-risk APOL1 genotypes defined by presence of two renal risk variants (RRVs). A pilot study 136 African ancestry living donors found that those with APOL1 high-risk genotypes had lower baseline kidney function and faster rates of kidney function decline after donation. To date, three retrospective studies identified a two-to-three times greater risk of allograft failure associated with kidneys from donors with high-risk APOL1 genotype. Active research initiatives seek to address unanswered questions, including reproducibility in large national samples, the role of 'second hits' injuries, and impact of recipient genotype, with a goal to build consensus on applications for policy and practice. SUMMARY As evidence evolves, APOL1 genotyping may have applications for organ quality scoring in deceased donor kidney allocation, and for the evaluation and selection of living donor candidates.
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Affiliation(s)
- Krista L Lentine
- Saint Louis University Center for Abdominal Transplantation, St. Louis, Missouri
| | - Roslyn B Mannon
- Division of Nephrology, Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
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Goldberg D, Doby B, Siminoff L, Shah M, Lynch R. Rejecting bias: The case against race adjustment for OPO performance in communities of color. Am J Transplant 2020; 20:2337-2342. [PMID: 32185873 DOI: 10.1111/ajt.15865] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 03/06/2020] [Accepted: 03/16/2020] [Indexed: 01/25/2023]
Abstract
In December of 2019, the Centers for Medicare and Medicaid Services (CMS) put out a notice of proposed rule-making for 42 CFR Part 486, specifically the section that covers the organ procurement organization (OPO) Conditions for Coverage. Most crucially, the proposed rule included two new OPO performance metrics using objective, standardized data from the Centers for Disease Control and Prevention (CDC). These new metrics would employ a denominator that included inpatient deaths from certain causes that could lead to organ donation, rather than the current unverifiable eligible death metric. Although there has been near-uniform support for replacing the eligible death denominator with CDC data, a source of contention is CMS's proposal not to adjust risk for race in their OPO outcome. Nonetheless, there have been calls for race and ethnicity to be included as risk-adjusted variables in the CMS donation metric. Herein, we lay out an argument as to why inclusion of race and ethnicity as risk adjustment variables in an OPO performance metric is not only statistically suspect but also will hide the inequities that are detrimental to optimal system performance and assurance that all patients have timely access to donation.
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Affiliation(s)
- David Goldberg
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Brianna Doby
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Laura Siminoff
- Division of Transplantation, Department of Surgery, University of Kentucky Medical Center, Lexington, Kentucky, USA
| | - Malay Shah
- Department of Social and Behavioral Sciences, College of Public Health, Temple University, Philadelphia, Pennsylvania, USA
| | - Raymond Lynch
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
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Trends in Living Donation by Race and Ethnicity Among Children With End-stage Renal Disease in the United States, 1995-2015. Transplant Direct 2020; 6:e570. [PMID: 32766425 PMCID: PMC7339334 DOI: 10.1097/txd.0000000000001008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 04/21/2020] [Accepted: 04/24/2020] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Living donor kidney transplants have declined among adults with end-stage renal disease (ESRD), with increases in racial/ethnic disparities over time. Secular trends in racial/ethnic disparities in living donor kidney transplantation have not been well studied in children. METHODS Using multivariable Cox modeling, we examined changes in living donor kidney transplant rates over time and probability of receiving living donor kidney transplantation within 2 years of incident ESRD by race/ethnicity among 19 772 children in the US Renal Data System, 1995-2015. We also examined racial/ethnic concordance between donors and recipients. RESULTS Overall, living donor kidney transplant rates declined by 3% annually since 1995 for all racial/ethnic groups except Asians for whom living donor kidney transplant rates remained stable; however, disparities persist. Compared with non-Hispanic white children, Hispanics were 42% less likely (adjusted hazard ratio: 0.58; 95% confidence interval: 0.49-0.67), Asians 39% less likely (0.61; 0.47-0.79), and blacks 66% less likely (0.34; 0.28-0.42) to receive living kidney donor transplantation within 2 years, even when accounting for deceased donor transplantation as a competing risk. Additionally, while 95% of non-Hispanic white children had non-Hispanic white donors, only 56% of Asian recipients had Asian donors (P < 0.001). Asian recipients were more likely to have nonrelated donors (P < 0.001). CONCLUSIONS There are ongoing declines in living donation for children with ESRD for uncertain reasons, and minority populations experience significantly reduced access to timely living donor transplant, even when accounting for changes in deceased donation and donor-recipient relationships.
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Mena-Gutierrez AM, Reeves-Daniel AM, Jay CL, Freedman BI. Practical Considerations for APOL1 Genotyping in the Living Kidney Donor Evaluation. Transplantation 2020; 104:27-32. [PMID: 31449181 PMCID: PMC6933073 DOI: 10.1097/tp.0000000000002933] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Association between the apolipoprotein L1 gene (APOL1) and nephropathy has altered the epidemiology of chronic kidney disease. In addition, donor APOL1 genotypes play important roles in the time to allograft failure in kidneys transplanted from deceased donors and the safety of living kidney donation. METHODS This article reviews genetic testing for inherited kidney disease in living kidney donors to improve donor safety. APOL1 genotyping in donors with recent African ancestry is considered. RESULTS Based on current data, transplant physicians should discuss APOL1 genotyping with potential living kidney donors self-reporting recent African ancestry. Until results from APOL1 Long-term Kidney Transplant Outcomes Network ancillary studies are available, we present practical approaches from our experience for considering APOL1 genotyping in the living donor evaluation. CONCLUSIONS Transplant physicians should inform potential living kidney donors at risk for APOL1-associated nephropathy about the gene and possibility of genetic testing early in the donor evaluation, well before scheduling the donor nephrectomy. Transplant programs must weigh risks of performing a donor nephrectomy in those with 2 APOL1 renal risk variants (high-risk genotypes), particularly younger individuals. Our program counsels kidney donors with APOL1 high-risk genotypes in the same fashion as with risk genotypes in other nephropathy genes. Because most African American kidney donor candidates lacking hypertension, proteinuria and reduced kidney function after workup will not possess APOL1 high-risk genotypes, genetic testing is unlikely to markedly increase donor declines and may reassure donors with regard to their long-term kidney outcomes, potentially increasing the number of African American donors.
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Affiliation(s)
- Alejandra M. Mena-Gutierrez
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine; Winston-Salem, North Carolina, USA
| | - Amber M. Reeves-Daniel
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine; Winston-Salem, North Carolina, USA
| | - Colleen L. Jay
- Department of Surgery, Wake Forest School of Medicine; Winston-Salem, North Carolina, USA
| | - Barry I. Freedman
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine; Winston-Salem, North Carolina, USA
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McIntosh T, Mohan S, Sawinski D, Iltis A, DuBois JM. Variation of ApoL1 Testing Practices for Living Kidney Donors. Prog Transplant 2019; 30:22-28. [PMID: 31838940 DOI: 10.1177/1526924819892917] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Tests exist for ApoL1 genetic variants to determine whether a potential donor's kidneys are at increased risk of kidney failure. Variants of the ApoL1 gene associated with increased risk are primarily found in people with West African ancestry. Given uncertainty about clinical implications of ApoL1 test results for living kidney donors and recipients and the lack of uniform guidelines for ApoL1 testing, transplant centers across the United States vary in ApoL1 testing practices. RESEARCH QUESTIONS (1) What approach do transplant centers take to determine whether prospective donors are of West African ancestry? (2)How do transplant centers engage potential donors during the ApoL1 testing process? (3) What do transplant centers identify as concerns and barriers to ApoL1 testing? and (4) What actions do transplant centers take when a potential donor has 2 ApoL1 risk variants? DESIGN We explored the current practices of transplant centers by surveying nephrologists and transplant surgeons at transplant centers evaluating the majority of black living donors in the United States. RESULTS About half of these transplant centers offered ApoL1 testing. Of those who offered ApoL1 testing, only half involved the donor in decision-making about donation when the donor has 2 risk variants. DISCUSSION Unaddressed differences in the priorities of transplant centers and black living donors may stigmatize black donors and undermine trust in the health-care and organ donation systems. Variation in transplant center testing practices points to the critical need for further research and community engagement to inform the development of guidelines for ApoL1 testing.
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Affiliation(s)
- Tristan McIntosh
- Division of General Medical Sciences, Department of Medicine, Washington University School of Medicine, St Louis, MO, USA
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine Columbia University Vagelos College of Physicians & Surgeons, New York, NY, USA.,Department of Epidemiology, Columbia University, Mailman School of Public Health, New York, NY, USA.,Columbia University Renal Epidemiology (CURE) Group, New York, NY, USA
| | - Deirdre Sawinski
- Renal, Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ana Iltis
- Department of Philosophy, Wake Forest University, Winston Salem, NC, USA.,Center for Bioethics Health and Society, Wake Forest University, Winston Salem, NC, USA
| | - James M DuBois
- Division of General Medical Sciences, Department of Medicine, Washington University School of Medicine, St Louis, MO, USA
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Umeukeje EM, Young BA. Genetics and ESKD Disparities in African Americans. Am J Kidney Dis 2019; 74:811-821. [PMID: 31606237 PMCID: PMC7373097 DOI: 10.1053/j.ajkd.2019.06.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 06/09/2019] [Indexed: 12/22/2022]
Abstract
African Americans have a 2- to 4-fold greater incidence of end-stage kidney disease (ESKD) than whites, which has long raised the possibility of a genetic cause for this disparity. Recent advances in genetic studies have shown a causal association of polymorphisms at the apolipoprotein L1 gene (APOL1) with the markedly increased risk for the nondiabetic component of the overall disparity in ESKD in African Americans. Although APOL1-associated kidney disease is thought to account for a substantial proportion of ESKD in African Americans, not all the increased risk for ESKD is accounted for, and a complete cataloging of disparities in genetic causes of ESKD eludes our current understanding of genetic-associated kidney disease. Genetic testing aids the screening, diagnosis, prognosis, and treatment of diseases with a genetic basis. Widespread use of genetic testing in clinical practice is limited by the small number of actionable genetic variants, limited health literacy of providers and patients, and underlying complex ethical, legal, and social issues. This perspective reviews racial and ethnic differences associated with genetic diseases and the development of ESKD in African Americans and discusses potential uncertainties associated with our current understanding of penetrance of genetically linked kidney disease and population-attributable risk percent.
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Affiliation(s)
- Ebele M Umeukeje
- Division of Nephrology, Vanderbilt University Medical Center, Nashville, TN; Vanderbilt Center for Kidney Disease, Nashville, TN
| | - Bessie A Young
- Nephrology, Hospital and Specialty Medicine and Center for Innovation for Veteran-Centered and Value Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, WA; Kidney Research Institute and Division of Nephrology, University of Washington, Seattle, WA.
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Muzaale AD, Massie AB, Al Ammary F, Henderson ML, Purnell TS, Holscher CM, Garonzik-Wang J, Locke JE, Snyder JJ, Lentine KL, Segev DL. Donor-Recipient Relationship and Risk of ESKD in Live Kidney Donors of Varied Racial Groups. Am J Kidney Dis 2019; 75:333-341. [PMID: 31732232 DOI: 10.1053/j.ajkd.2019.08.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Accepted: 08/19/2019] [Indexed: 12/14/2022]
Abstract
RATIONALE & OBJECTIVE Risk factors for kidney failure are the basis of live kidney donor candidate evaluation. We quantified risk for end-stage kidney disease (ESKD) by the biological relationship of the donor to the recipient, a risk factor that is not addressed by current clinical practice guidelines. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS A cohort of 143,750 US kidney donors between 1987 and 2017. EXPOSURE Biological relationship of donor and recipient. OUTCOME ESKD. Donors' records were linked to national dialysis and transplantation registries to ascertain development of the outcome. ANALYTIC APPROACH Donors were observed over a median of 12 (interquartile range, 6-18; maximum, 30) years. Survival analysis methods that account for the competing risk for death were used. RESULTS Risk for ESKD varied by orders of magnitude across donor-recipient relationship categories. For Asian donors, risks compared with unrelated donors were 259.4-fold greater for identical twins (95% CI, 19.5-3445.6), 4.7-fold greater for full siblings (95% CI, 0.5-41.0), 3.5-fold greater for offspring (95% CI, 0.6-39.5), 1.0 for parents, and 1.0 for half-sibling or other biological relatives. For black donors, risks were 22.5-fold greater for identical twin donors (95% CI, 4.7-107.0), 4.1-fold for full siblings (95% CI, 2.1-7.8), 2.7-fold for offspring (95% CI, 1.4-5.4), 3.1-fold for parents (95% CI, 1.4-6.8), and 1.3-fold for half-sibling or other biological relatives (95% CI, 0.5-3.3). For white donors, risks were 3.5-fold greater for identical twin donors (95% CI, 0.5-25.3), 2.0-fold for full siblings (95% CI, 1.4-2.8), 1.4-fold for offspring (95% CI, 0.9-2.3), 2.9-fold for parents (95% CI, 2.0-4.1), and 0.8-fold for half-sibling or other biological relatives (95% CI, 0.3-1.6). LIMITATIONS Insufficient sample size in some race and relationship groups. Absence of data for family history of kidney disease for donors biologically unrelated to their recipients. CONCLUSIONS Marked differences in risk for ESKD across types of donor-recipient relationship were observed for Asian, black, and white donors. These findings warrant further validation with more robust data to better inform clinical practice guidelines.
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Affiliation(s)
- Abimereki D Muzaale
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Allan B Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Fawaz Al Ammary
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Macey L Henderson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Acute and Chronic Care, Johns Hopkins School of Nursing, Baltimore, MD
| | - Tanjala S Purnell
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Courtenay M Holscher
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Jayme E Locke
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Jon J Snyder
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, MN
| | - Krista L Lentine
- Saint Louis University Center for Abdominal Transplantation, St. Louis, MO
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD; Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, MN
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13
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Neugut YD, Mohan S, Gharavi AG, Kiryluk K. Cases in Precision Medicine: APOL1 and Genetic Testing in the Evaluation of Chronic Kidney Disease and Potential Transplant. Ann Intern Med 2019; 171:659-664. [PMID: 31590185 PMCID: PMC7441647 DOI: 10.7326/m19-1389] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
This article discusses potential indications for genetic testing in an African American patient with chronic kidney disease who is being evaluated for a kidney transplant. Two known risk variants in the APOL1 (apolipoprotein L1) gene predispose to kidney disease and are found almost exclusively in persons of African ancestry. APOL1 risk variants are considered, including whether clinicians should incorporate genetic testing in the screening process for living kidney donors. In addition to APOL1 testing, the role of diagnostic exome sequencing in evaluating potential transplant recipients and donors with a positive family history of kidney disease is discussed.
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Affiliation(s)
- Y Dana Neugut
- Columbia University, New York, New York (Y.D.N., S.M., A.G.G., K.K.)
| | - Sumit Mohan
- Columbia University, New York, New York (Y.D.N., S.M., A.G.G., K.K.)
| | - Ali G Gharavi
- Columbia University, New York, New York (Y.D.N., S.M., A.G.G., K.K.)
| | - Krzysztof Kiryluk
- Columbia University, New York, New York (Y.D.N., S.M., A.G.G., K.K.)
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14
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Mohan S, Iltis AS, Sawinski D, DuBois JM. APOL1 Genetic Testing in Living Kidney Transplant Donors. Am J Kidney Dis 2019; 74:538-543. [PMID: 30982552 PMCID: PMC6756958 DOI: 10.1053/j.ajkd.2019.02.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 02/02/2019] [Indexed: 12/29/2022]
Abstract
The presence of 2 apolipoprotein L1 gene (APOL1) risk variants is associated with increased risk for chronic kidney disease and end-stage kidney disease. Inferior allograft outcomes following transplantation with kidneys from donors with 2 risk variants have also been reported. These data, coupled with anecdotal case reports and a recent cohort study of living donors, raise important questions about the potential increased kidney disease risk for living donors with APOL1 risk variants and the need for testing as part of the standard living donor evaluation process. We identify a series of questions that are central to the development of clinical policy regarding APOL1 testing of potential living kidney donors given the current uncertainty over the clinical implications of having 2 risk variants. We explore the ethical challenges that arise when determining when and to whom APOL1 testing should be offered, what potential donors should be told about APOL1 testing, how test results should be used to determine suitability for donation, if and when recipients should have access to results, and how clinical policy regarding APOL1 testing should be established.
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Affiliation(s)
- Sumit Mohan
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY; Columbia University Renal Epidemiology (CURE) Group, New York, NY.
| | - Ana S Iltis
- Center for Bioethics Health and Society, Wake Forest University, Winston Salem, NC; Department of Philosophy, Wake Forest University, Winston Salem, NC
| | - Deirdre Sawinski
- Renal, Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - James M DuBois
- Division of General Medical Sciences, Washington University School of Medicine, St. Louis, MO
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15
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Freedman BI, Limou S, Ma L, Kopp JB. APOL1-Associated Nephropathy: A Key Contributor to Racial Disparities in CKD. Am J Kidney Dis 2019; 72:S8-S16. [PMID: 30343724 DOI: 10.1053/j.ajkd.2018.06.020] [Citation(s) in RCA: 94] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 06/25/2018] [Indexed: 01/09/2023]
Abstract
Genetic methodologies are improving our understanding of the pathophysiology in diverse diseases. Breakthroughs have been particularly impressive in nephrology, for which marked disparities exist in rates and etiologic classifications of end-stage kidney disease between African Americans and European Americans. Discovery of the apolipoprotein L1 gene (APOL1) association with focal segmental glomerulosclerosis, human immunodeficiency virus (HIV)-associated nephropathy, lupus nephritis, sickle cell nephropathy, and solidified glomerulosclerosis, as well as more rapid failure of transplanted kidneys from donors with APOL1 renal-risk genotypes, has improved our understanding of nondiabetic nephropathy. Environmental factors acting through natural selection in sub-Saharan African populations likely underlie this association. This article describes the discovery of chromosome 22q renal-risk variants and their worldwide distribution, reviews the epidemiology and pathology of APOL1-associated nephropathies, and explores several proposed mechanisms of kidney injury identified in cell culture and animal models. Detection of APOL1 associations with kidney diseases and delineation of injury pathways brings hope for effective treatment for these kidney diseases.
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Affiliation(s)
- Barry I Freedman
- Section on Nephrology, Department of Internal Medicine; Wake Forest School of Medicine, Winston-Salem, NC.
| | - Sophie Limou
- Centre de Recherche en Transplantation et Immunologie (CRTI) UMR1064, INSERM, Université de Nantes, Nantes, France; Institut de Transplantation Urologie et Néphrologie (ITUN), CHU Nantes, Nantes, France; Ecole Centrale de Nantes, Nantes, France
| | - Lijun Ma
- Section on Nephrology, Department of Internal Medicine; Wake Forest School of Medicine, Winston-Salem, NC
| | - Jeffrey B Kopp
- Kidney Disease Section, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD.
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16
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Werbel WA, Durand CM. Solid Organ Transplantation in HIV-Infected Recipients: History, Progress, and Frontiers. Curr HIV/AIDS Rep 2019; 16:191-203. [PMID: 31093920 PMCID: PMC6579039 DOI: 10.1007/s11904-019-00440-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW End-stage organ disease prevalence is increasing among HIV-infected (HIV+) individuals. Trial and registry data confirm that solid organ transplantation (SOT) is efficacious in this population. Optimizing access to transplant and decreasing complications represent active frontiers. RECENT FINDINGS HIV+ recipients historically experienced 2-4-fold higher rejection. Integrase strand transferase inhibitors (INSTIs) minimize drug interactions and may reduce rejection along with lymphodepleting induction immunosuppression. Hepatitis C virus (HCV) coinfection has been associated with inferior outcomes, yet direct-acting antivirals (DAAs) may mitigate this. Experience in South Africa and the US HIV Organ Policy Equity (HOPE) Act support HIV+ donor to HIV+ recipient (HIV D+/R+) transplantation. SOT is the optimal treatment for end-stage organ disease in HIV+ individuals. Recent advances include use of INSTIs and DAAs in transplant recipients; however, strategies to improve access to transplant are needed. HIV D+/R+ transplantation is under investigation and may improve access and provide insights for HIV cure and pathogenesis research.
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Affiliation(s)
- William A. Werbel
- Department of Medicine, Johns Hopkins University School
of Medicine, Baltimore, MD
| | - Christine M. Durand
- Department of Medicine, Johns Hopkins University School
of Medicine, Baltimore, MD
- Sidney Kimmel Cancer Center, Johns Hopkins University
School of Medicine, Baltimore, MD
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17
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Abstract
Kidney donors face a small but definite risk of end-stage renal disease 15 to 30 years postdonation. The development of proteinuria, hypertension with gradual decrease in kidney function in the donor after surgical resection of 1 kidney, has been attributed to hyperfiltration. Genetic variations, physiological adaptations, and comorbidities exacerbate the hyperfiltration-induced loss of kidney function in the years after donation. A focus on glomerular hemodynamics and capillary pressure has led to the development of drugs that target the renin-angiotensin-aldosterone system (RAAS), but these agents yield mixed results in transplant recipients and donors. Recent work on glomerular biomechanical forces highlights the differential effects of tensile stress and fluid flow shear stress (FFSS) from hyperfiltration. Capillary wall stretch due to glomerular capillary pressure increases tensile stress on podocyte foot processes that cover the capillary. In parallel, increased flow of the ultrafiltrate due to single-nephron glomerular filtration rate elevates FFSS on the podocyte cell body. Although tensile stress invokes the RAAS, FFSS predominantly activates the cyclooxygenase 2-prostaglandin E2-EP2 receptor axis. Distinguishing these 2 mechanisms is critical, as current therapeutic approaches focus on the RAAS system. A better understanding of the biomechanical forces can lead to novel therapeutic agents to target FFSS through the cyclooxygenase 2-prostaglandin E2-EP2 receptor axis in hyperfiltration-mediated injury. We present an overview of several aspects of the risk to transplant donors and discuss the relevance of FFSS in podocyte injury, loss of glomerular barrier function leading to albuminuria and gradual loss of renal function, and potential therapeutic strategies to mitigate hyperfiltration-mediated injury to the remaining kidney.
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18
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Gordon EJ, Wicklund C, Lee J, Sharp RR, Friedewald J. A National Survey of Transplant Surgeons and Nephrologists on Implementing Apolipoprotein L1 (APOL1) Genetic Testing Into Clinical Practice. Prog Transplant 2018; 29:26-35. [DOI: 10.1177/1526924818817048] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Introduction: There is debate over whether Apolipoprotein L1 (APOL1) gene risk variants contribute to African American (AA) live donors’ (LD) increased risk of kidney failure. Little is known about factors influencing physicians’ integration of APOL1 genetic testing of AA LDs into donor evaluation. Design: We conducted a cross-sectional survey, informed by Roger’s Diffusion of Innovations theory, among nephrology and surgeon members of the American Society of Nephrology, American Society of Transplantation, and American Society of Transplant Surgeons about their practices of and attitudes about APOL1 genetic testing of AA potential LDs. Descriptive statistics and bivariate analyses were performed. Results: Of 383 completed surveys, most physicians believed that APOL1 testing can help AA LDs make more informed donation decisions (87%), and the addition of APOL1 testing offers better clinical information about AA LD’s eligibility for donation than existing evaluation approaches (74%). Among respondents who evaluate LDs (n = 345), 63% would definitely or probably begin or continue using APOL1 testing in the next year, however, few use APOL1 testing routinely (4%) or on a case-by-case basis (14%). Most did not know the right clinical scenario to order APOL1 testing (59%), but would use educational materials to counsel AA LDs about APOL1 testing (97%). Discussion: Although physicians were highly supportive of APOL1 genetic testing for AA LDs, few physicians use APOL1 testing. As more physicians intend to use APOL1 testing, an ethical framework and clinical decision support are needed presently to assist clinicians in clarifying the proper indication of APOL1 genetic testing.
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Affiliation(s)
- Elisa J. Gordon
- Division of Transplantation, Department of Surgery, Center for Healthcare Studies, Center for Bioethics and Medical Humanities, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Catherine Wicklund
- Center for Genetic Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jungwha Lee
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Richard R. Sharp
- Biomedical Ethics Research Program Mayo Clinic, Rochester, MN, USA
| | - John Friedewald
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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19
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Ross LF, Thistlethwaite JR. Developing an ethics framework for living donor transplantation. JOURNAL OF MEDICAL ETHICS 2018; 44:843-850. [PMID: 29973389 DOI: 10.1136/medethics-2018-104762] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Revised: 05/28/2018] [Accepted: 05/31/2018] [Indexed: 06/08/2023]
Abstract
Both living donor transplantation and human subjects research expose one set of individuals to clinical risks for the clinical benefits of others. In the Belmont Report, the National Commission for the Protection of Human Subjects of Biomedical and Behavior Research (National Commission) articulated three principles to serve as the basis for a research ethics framework: respect for persons, beneficence and justice. In contrast, living donor transplantation lacks a framework. In this manuscript, we adapt the three principles articulated in the Belmont Report to serve as the foundation for an ethics framework for living donor transplantation which we supplement with the principles of vulnerability and responsibility. The National Commission supported additional protections for vulnerable groups of potential research participants. In 2001, Kenneth Kipnis effectively argued that the concept of vulnerable groups failed to explore in what ways particular groups of people were vulnerable, thereby risking unnecessary protections for some and inadequate protections for others. He proposed a taxonomy that explored different types of vulnerabilities that all research participants may experience to provide a more robust framework for human subjects protections, which we adapt to living donors. Robert Goodin claims that health professionals, who stand in special relationship with patients, are responsible for promoting and protecting their well-being. In living donor transplantation, the donor transplant team is responsible for empowering prospective donors to address their vulnerabilities and/or for protecting those who cannot by disqualifying them from donation.
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Affiliation(s)
- Lainie F Ross
- Department of Pediatrics, University of Chicago, Chicago, Illinois, USA
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
- MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois, USA
| | - J Richard Thistlethwaite
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
- MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois, USA
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20
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Gordon EJ, Amόrtegui D, Blancas I, Wicklund C, Friedewald J, Sharp RR. African American Living Donors' Attitudes About APOL1 Genetic Testing: A Mixed Methods Study. Am J Kidney Dis 2018; 72:819-833. [PMID: 30360961 PMCID: PMC6252162 DOI: 10.1053/j.ajkd.2018.07.017] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 07/24/2018] [Indexed: 12/16/2022]
Abstract
RATIONALE & OBJECTIVE African American live kidney donors ("donors") have a greater risk for kidney failure than European American donors. Apolipoprotein L1 gene (APOL1) variants in African Americans may be associated with this disparity. STUDY DESIGN Cross-sectional mixed-methods design. SETTING & PARTICIPANTS African American donors at 1 transplantation center. ANALYTICAL APPROACH Semistructured interviews assessed attitudes about APOL1 genetic testing, willingness to undergo APOL1 testing, hypothetical decisions about donating with 2 APOL1 variants, and demographics. Surveys assessed perceptions of ethnic identity and genetics knowledge. Interview transcriptions were analyzed using thematic analysis. Survey data were analyzed using descriptive statistics. RESULTS 23 donors participated in semistructured interviews. Most (96%) reported that transplantation centers should routinely offer APOL1 genetic testing to all African American potential donors. Most (87%) would have been willing to undergo APOL1 testing before donating. Although study participants noted that APOL1 testing may deter African American potential donors from donating, most (61%) would have donated even if they had 2 high-risk APOL1 variants. Several themes emerged. Study participants believed that APOL1 testing was beneficial for providing information to help donors make informed donation decisions. Participants expressed concern about APOL1 variants placing donors at harm for kidney failure, and therefore valued taking preventive health measures. Participants believed that potential donors would experience psychological distress from learning that they have 2 gene variants and could harm their recipients. Participants were apprehensive about insurance coverage and costs of APOL1 testing and feared that APOL1 genetic test results could discriminate against African Americans. LIMITATIONS Findings may not be generalizable to African American potential donors. CONCLUSIONS Findings suggest that African American donors support APOL1 genetic testing yet fear that APOL1 variants and genetic testing could adversely affect donors' health and ethnic identity. Transplantation centers using APOL1 genetic testing should address African American donors' concerns about APOL1 genetic testing to optimize future donors' informed consent practices.
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Affiliation(s)
- Elisa J Gordon
- Division of Transplantation, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL; Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, IL; Center for Bioethics and Medical Humanities, Feinberg School of Medicine, Northwestern University, Chicago, IL.
| | - Daniela Amόrtegui
- Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Isaac Blancas
- Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Catherine Wicklund
- Center for Genetic Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - John Friedewald
- Division of Transplantation, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL; Division of Internal Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
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21
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Young BA, Fullerton SM, Wilson JG, Cavanaugh K, Blacksher E, Spigner C, Himmelfarb J, Burke W. Clinical Genetic Testing for APOL1: Are we There Yet? Semin Nephrol 2018; 37:552-557. [PMID: 29110763 DOI: 10.1016/j.semnephrol.2017.07.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
End-stage renal disease (ESRD) disproportionately affects African Americans, who are two to four times more likely than European Americans to develop ESRD. Two independent variants of the apolipoprotein L1 (APOL1) gene, G1 and G2, have been associated with a 7- to 10-fold greater risk of developing nondiabetic ESRD in African Americans. Those who inherit two risk variants (G1/G1, G2/G2, or G1/G2) are also more likely to develop ESRD at a younger age and to have progression of chronic kidney disease. Currently, it is not known what proportion of persons with high-risk genotypes will develop ESRD in the general population, the exact mechanism of injury for APOL1-related risk, its relation to environmental exposures, or whether patients with comorbid conditions are more likely to develop ESRD. To address the above uncertainties, research that includes assessment of APOL1 status is needed before guidelines for general testing can be endorsed. Currently, APOL1 testing has been proposed as part of kidney transplant protocols both for living donors and recipients. However, because of uncertainties regarding the clinical implications of APOL1 variants, testing could generate confusion, anxiety, or stigma. Multiple forms of evidence, including the views of community members, are needed to support responsible approaches to providing information about APOL1 status as part of clinical care or in population screening. Informed consent with subsequent counseling regarding the risks and benefits of APOL1 testing should be considered for patients at high risk.
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Affiliation(s)
- Bessie A Young
- Nephrology Section, Hospital and Specialty Medicine, VA Puget Sound Health Care System, Seattle, WA; Kidney Research Institute and Division of Nephrology, University of Washington, Seattle, WA.
| | | | - James G Wilson
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, MS
| | - Kerri Cavanaugh
- Division of Nephrology, Vanderbilt University, Nashville, TN
| | - Erika Blacksher
- Bioethics and Humanities, University of Washington, Seattle, WA
| | - Clarence Spigner
- Department of Health Services, School of Public Health, University of Washington, Seattle, WA
| | - Jonathan Himmelfarb
- Kidney Research Institute and Division of Nephrology, University of Washington, Seattle, WA
| | - Wylie Burke
- Bioethics and Humanities, University of Washington, Seattle, WA
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22
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Freedman BI, Moxey-Mims M. The APOL1 Long-Term Kidney Transplantation Outcomes Network-APOLLO. Clin J Am Soc Nephrol 2018; 13:940-942. [PMID: 29703792 PMCID: PMC5989686 DOI: 10.2215/cjn.01510218] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Barry I. Freedman
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina; and
| | - Marva Moxey-Mims
- Division of Nephrology, Children’s National Health System, Department of Pediatrics, The George Washington University School of Medicine and Health Services, Washington, District of Columbia
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23
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Wainright JL, Robinson AM, Wilk AR, Klassen DK, Cherikh WS, Stewart DE. Risk of ESRD in prior living kidney donors. Am J Transplant 2018; 18:1129-1139. [PMID: 29392849 DOI: 10.1111/ajt.14678] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 01/23/2018] [Accepted: 01/24/2018] [Indexed: 01/25/2023]
Abstract
We studied End-Stage Renal Disease (ESRD) in living kidney donors (LKDs) who donated in the United States between 1994 and 2016 (n = 123 526), using Organ Procurement and Transplantation Network and Centers for Medicare and Medicaid Services data. Two hundred eighteen LKDs developed ESRD, with a median of 11.1 years between donation and ESRD. Absolute 20-year risk was low but not uniform, with risk associated with race, age, and sex and increasing exponentially over time. LKDs had increased risk of ESRD if they were male (adjusted hazard ratio [aHR]: 1.75, 95% confidence interval [95%CI]: 1.33-2.31), had higher BMI (aHR: 1.34 per 5 kg/m2 , 95%CI: 1.10-1.64) or lower estimated GFR (aHR: 0.89 per 10 mL/min, 95% CI: 0.80-0.99), were first-degree relatives of the recipient (parent: [aHR: 2.01, 95% CI: 1.26-3.21]; full sibling [aHR: 1.87, 95%CI: 1.23-2.84]; identical twin [aHR: 19.79, 95%CI: 7.65-51.24]), or lived in lower socioeconomic status neighborhoods at donation (aHR: 0.87 per $10k increase; 95%CI: 0.77-0.99). We found a significant interaction between donation age and race, with higher risk at older ages for white LKDs (aHR: 1.26 per decade, 95%CI: 1.04-1.54), but higher risk at younger ages for black LKDs (aHR: 0.75 per decade, 95%CI: 0.57-0.99). These findings further inform risk assessment of potential LKDs.
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Affiliation(s)
| | - Amanda M Robinson
- Research Department, United Network for Organ Sharing, Richmond, VA, USA
| | - Amber R Wilk
- Research Department, United Network for Organ Sharing, Richmond, VA, USA
| | - David K Klassen
- Office of the Chief Medical Officer, United Network for Organ Sharing, Richmond, VA, USA
| | - Wida S Cherikh
- Research Department, United Network for Organ Sharing, Richmond, VA, USA
| | - Darren E Stewart
- Research Department, United Network for Organ Sharing, Richmond, VA, USA
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24
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Abstract
The pathogenesis of many common etiologies of nephropathy has been informed by recent molecular genetic breakthroughs. It now is apparent that the ethnic disparity in the risk for nondiabetic chronic kidney disease between African Americans and European Americans is explained largely by variation in the apolipoprotein L1 gene (APOL1). The presence of two APOL1 renal risk variants markedly increases an individual's risk for kidney disease. In transplantation, kidneys from deceased African Americans with two APOL1 renal risk variants have shorter survival intervals after engraftment, regardless of the ethnicity of the recipient. Precision medicine will transform the clinical practice of nephrology and kidney transplantation, and play an important role in the allocation of kidneys from deceased and living kidney donors with recent African ancestry. This article reviews existing data on APOL1 in deceased-donor and living-donor kidney transplantation. It considers the impact of including APOL1 genotyping in decisions on the allocation and discard of deceased-donor kidneys, as well as the selection of living donors.
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Affiliation(s)
- Barry I Freedman
- Section on Nephrology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC.
| | - Jayme E Locke
- Division of Transplantation, Department of Surgery, University of Alabama at Birmingham School of Medicine, Birmingham, AL; Comprehensive Transplant Institute, University of Alabama at Birmingham School of Medicine, Birmingham, AL
| | - Amber M Reeves-Daniel
- Section on Nephrology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Bruce A Julian
- Comprehensive Transplant Institute, University of Alabama at Birmingham School of Medicine, Birmingham, AL; Division of Nephrology, Department of Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, AL
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25
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Kalil RS, Smith RJ, Rastogi P, Katz DA, Thomas CP. Late Reoccurrence of Collapsing FSGS After Transplantation of a Living-Related Kidney Bearing APOL 1 Risk Variants Without Disease Evident in Donor Supports the Second Hit Hypothesis. Transplant Direct 2017; 3:e185. [PMID: 28795137 PMCID: PMC5540623 DOI: 10.1097/txd.0000000000000697] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 05/05/2017] [Indexed: 11/26/2022] Open
Affiliation(s)
- Roberto S. Kalil
- 1 Kidney Transplant Program, Iowa City VAMC, Iowa City, IA
- 2 Department of Internal Medicine, Division of Nephrology, Carver College of Medicine, Iowa City, IA
| | - Richard J. Smith
- 2 Department of Internal Medicine, Division of Nephrology, Carver College of Medicine, Iowa City, IA
- 3 The Iowa Institute of Human Genetics, University of Iowa, Iowa City, IA
- 4 Department of Otolaryngology, Carver College of Medicine, Iowa City, IA
| | - Prerna Rastogi
- 5 Department of Pathology, Carver College of Medicine, Iowa City, IA
| | - Daniel A. Katz
- 1 Kidney Transplant Program, Iowa City VAMC, Iowa City, IA
- 6 Department of Surgery, Organ Transplant Center, Carver College of Medicine, Iowa City, IA
| | - Christie P. Thomas
- 1 Kidney Transplant Program, Iowa City VAMC, Iowa City, IA
- 2 Department of Internal Medicine, Division of Nephrology, Carver College of Medicine, Iowa City, IA
- 3 The Iowa Institute of Human Genetics, University of Iowa, Iowa City, IA
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26
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Lentine KL, Kasiske BL, Levey AS, Adams PL, Alberú J, Bakr MA, Gallon L, Garvey CA, Guleria S, Li PKT, Segev DL, Taler SJ, Tanabe K, Wright L, Zeier MG, Cheung M, Garg AX. KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors. Transplantation 2017; 101:S1-S109. [PMID: 28742762 PMCID: PMC5540357 DOI: 10.1097/tp.0000000000001769] [Citation(s) in RCA: 198] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 03/20/2017] [Indexed: 12/17/2022]
Abstract
The 2017 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors is intended to assist medical professionals who evaluate living kidney donor candidates and provide care before, during and after donation. The guideline development process followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach and guideline recommendations are based on systematic reviews of relevant studies that included critical appraisal of the quality of the evidence and the strength of recommendations. However, many recommendations, for which there was no evidence or no systematic search for evidence was undertaken by the Evidence Review Team, were issued as ungraded expert opinion recommendations. The guideline work group concluded that a comprehensive approach to risk assessment should replace decisions based on assessments of single risk factors in isolation. Original data analyses were undertaken to produce a "proof-in-concept" risk-prediction model for kidney failure to support a framework for quantitative risk assessment in the donor candidate evaluation and defensible shared decision making. This framework is grounded in the simultaneous consideration of each candidate's profile of demographic and health characteristics. The processes and framework for the donor candidate evaluation are presented, along with recommendations for optimal care before, during, and after donation. Limitations of the evidence are discussed, especially regarding the lack of definitive prospective studies and clinical outcome trials. Suggestions for future research, including the need for continued refinement of long-term risk prediction and novel approaches to estimating donation-attributable risks, are also provided.In citing this document, the following format should be used: Kidney Disease: Improving Global Outcomes (KDIGO) Living Kidney Donor Work Group. KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors. Transplantation. 2017;101(Suppl 8S):S1-S109.
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Affiliation(s)
| | | | | | | | - Josefina Alberú
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | | | | | | | | | - Dorry L. Segev
- Johns Hopkins University, School of Medicine, Baltimore, MD
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Newell KA, Formica RN, Gill JS, Schold JD, Allan JS, Covington SH, Wiseman AC, Chandraker A. Integrating APOL1 Gene Variants Into Renal Transplantation: Considerations Arising From the American Society of Transplantation Expert Conference. Am J Transplant 2017; 17:901-911. [PMID: 27997071 DOI: 10.1111/ajt.14173] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 12/02/2016] [Accepted: 12/07/2016] [Indexed: 01/25/2023]
Abstract
Thirteen percent of individuals of African ancestry express two variant copies of the gene encoding apolipoprotein 1 (APOL1) that has been associated with an increased risk of end-stage renal disease (ESRD) in the general population. Limited studies suggest that the survival of transplanted kidneys from donors expressing two APOL1 risk alleles is inferior to that of kidneys from donors with zero or one risk allele. In living kidney donation, two case reports describe donors expressing two APOL1 risk alleles who developed ESRD. Given the potential impact of APOL1 variants on the utility and safety of kidney transplantation and living kidney donation, the American Society of Transplantation convened a meeting with the goals of summarizing the current state of knowledge with respect to transplantation and APOL1, identifying knowledge gaps and studies to address these gaps, and considering approaches to integrating APOL1 into clinical practice. The authors recognize that current data are not sufficient to support traditional evidence-based guidelines but also recognize that it may require several years to generate the necessary data. Thus, approaches as to how APOL1 might currently be integrated into the clinical decision-making process were considered. This report summarizes the group's deliberations.
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Affiliation(s)
- K A Newell
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - R N Formica
- Department of Medicine, Yale University School of Medicine, New Haven, CN
| | - J S Gill
- Division of Nephrology, Centre for Health Evaluation and Outcomes Sciences, University of British Columbia, Vancouver, Canada
| | - J D Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - J S Allan
- Department of Surgery, Massachusetts General Hospital, Harvard University, Boston, MA
| | | | | | - A Chandraker
- Schuster Family Transplantation Research Center, Renal Division, Brigham & Women's Hospital, Harvard Medical School, Boston, MA
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Abstract
Ever since the discovery of the major histocompatibility complex, scientific and clinical understanding in the field of transplantation has been advanced through genetic and genomic studies. Candidate-gene approaches and recent genome-wide association studies (GWAS) have enabled a deeper understanding of the complex interplay of the donor-recipient interactions that lead to transplant tolerance or rejection. Genetic analysis in transplantation, when linked to demographic and clinical outcomes, has the potential to drive personalized medicine by enabling individualized risk stratification and immunosuppression through the identification of variants associated with immune-mediated complications, post-transplant disease or alterations in drug-metabolizing genes.
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Affiliation(s)
- Joshua Y C Yang
- Division of Transplant Surgery, University of California San Francisco, 513 Parnassus Avenue, San Francisco, California 94143, USA
| | - Minnie M Sarwal
- Division of Transplant Surgery, University of California San Francisco, 513 Parnassus Avenue, San Francisco, California 94143, USA
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Zwang NA, Shetty A, Sustento-Reodica N, Gordon EJ, Leventhal J, Gallon L, Friedewald JJ. APOL1-Associated End-Stage Renal Disease in a Living Kidney Transplant Donor. Am J Transplant 2016; 16:3568-3572. [PMID: 27588375 DOI: 10.1111/ajt.14035] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 08/09/2016] [Accepted: 08/27/2016] [Indexed: 01/25/2023]
Abstract
Homozygosity for apolipoprotein-L1 (APOL1) risk variants has emerged as an important predictor of renal disease in individuals of African descent over the past several years. Additionally, these risk variants may be important predictors of renal allograft failure when present in a living or deceased donor. Currently, there is no universal recommendation for screening of potential donors. We present a case of end-stage renal disease with focal segmental glomerulosclerosis in a living donor 7 years following donor nephrectomy. Genetic assessment revealed homozygosity for the G1 high-risk APOL1 variant.
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Affiliation(s)
- N A Zwang
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL.,McGaw Medical Center of Northwestern University, Chicago, IL
| | - A Shetty
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - N Sustento-Reodica
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - E J Gordon
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL.,Center for Healthcare Studies, and Center for Bioethics and Medical Humanities, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - J Leventhal
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - L Gallon
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - J J Friedewald
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
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Ross LF, Thistlethwaite JR. Introducing Genetic Tests With Uncertain Implications in Living Donor Kidney Transplantation. Prog Transplant 2016; 26:203-6. [DOI: 10.1177/1526924816654608] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Genetic mutations in apolipoprotein L1 (ApoL1) are associated with kidney disease. Apolipoprotein L1 mutations are common in African Americans (∼39% and 12% have 1 and 2 high-risk alleles, respectively). Carrying 2 ApoL1 risk alleles may explain much of the excess rate of kidney failure in African Americans compared to European Americans. Apolipoprotein L1 also has implications for kidney transplantation. Kidney grafts from deceased donors with 2 ApoL1 risk alleles have worse graft survival, but outcomes appear unaffected by recipient ApoL1 status. Unknown is whether donation increases the risk of kidney failure in living donors with 2 ApoL1 risk alleles and whether their donated kidneys have worse graft survival. There are 4 options to consider: (1) remain silent about ApoL1 risk alleles and renal failure and wait for more data; (2) counsel about race, ApoL1, and subsequent renal failure abstractly but remain agnostic about donor testing until more data are available; (3) provide counseling and encourage genotyping of prospective living donors of African ancestry as part of the living donor workup; or (4) mandate testing of all prospective living donors. We support option 3, and recommend, with donor permission, to discuss the results with potential recipients to promote informed decision-making. We also argue for a voluntary donor registry that collects long-term follow-up information. We provide ethical arguments to support these recommendations.
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Affiliation(s)
- Lainie Friedman Ross
- MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL, USA
- Department of Surgery, Section of Transplantation, University of Chicago, Chicago, IL, USA
- Department of Pediatrics, Section of Academic Pediatrics, University of Chicago, Chicago, IL, USA
| | - J. Richard Thistlethwaite
- MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL, USA
- Department of Surgery, Section of Transplantation, University of Chicago, Chicago, IL, USA
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31
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Hu CAA, Ray PE. How complicated can it be? The link between APOL1 risk variants and lipoprotein heterogeneity in kidney and cardiovascular diseases. Nephrol Dial Transplant 2016; 31:509-11. [PMID: 26433015 PMCID: PMC4902870 DOI: 10.1093/ndt/gfv357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Accepted: 09/14/2015] [Indexed: 08/30/2023] Open
Abstract
….the findings of Gutierrez et al. (22) add more fuel to the ongoing controversy regarding the association of APOL1 G1/G2 risk status with cardiovascular outcome among African Americans. However, if we acknowledge that the APOL1 risk alleles may directly modify the circulating levels of small HDL and/or other factors and induce a proatherogenic state that precipitates CKD and cardiovascular complications, then we should begin to answer several questions ….
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Affiliation(s)
- Chien-An A. Hu
- Department of Biochemistry and Molecular Biology, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Patricio E. Ray
- Children's National Medical Center, Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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Grams ME, Rebholz CM, Chen Y, Rawlings AM, Estrella MM, Selvin E, Appel LJ, Tin A, Coresh J. Race, APOL1 Risk, and eGFR Decline in the General Population. J Am Soc Nephrol 2016; 27:2842-50. [PMID: 26966015 DOI: 10.1681/asn.2015070763] [Citation(s) in RCA: 113] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 01/04/2016] [Indexed: 12/23/2022] Open
Abstract
The APOL1 high-risk genotype, present in approximately 13% of blacks in the United States, is a risk factor for kidney function decline in populations with CKD. It is unknown whether genetic screening is indicated in the general population. We evaluated the prognosis of APOL1 high-risk status in participants in the population-based Atherosclerosis Risk in Communities (ARIC) study, including associations with eGFR decline, variability in eGFR decline, and related adverse health events (AKI, ESRD, hypertension, diabetes, cardiovascular disease, pre-ESRD and total hospitalization rate, and mortality). Among 15,140 ARIC participants followed from 1987-1989 (baseline) to 2011-2013, 75.3% were white, 21.5% were black/APOL1 low-risk, and 3.2% were black/APOL1 high-risk. In a demographic-adjusted analysis, blacks had a higher risk for all assessed adverse health events; however, in analyses adjusted for comorbid conditions and socioeconomic status, blacks had a higher risk for hypertension, diabetes, and ESRD only. Among blacks, the APOL1 high-risk genotype associated only with higher risk of ESRD in a fully adjusted analysis. Black race and APOL1 high-risk status were associated with faster eGFR decline (P<0.001 for each). However, we detected substantial overlap among the groups: median (10th-90th percentile) unadjusted eGFR decline was 1.5 (1.0-2.2) ml/min per 1.73 m(2) per year for whites, 2.1 (1.4-3.1) ml/min per 1.73 m(2) per year for blacks with APOL1 low-risk status, and 2.3 (1.5-3.5) ml/min per 1.73 m(2) per year for blacks with APOL1 high-risk status. The high variability in eGFR decline among blacks with and without the APOL1 high-risk genotype suggests that population-based screening is not yet justified.
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Affiliation(s)
- Morgan E Grams
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; and Department of Epidemiology and
| | | | | | | | - Michelle M Estrella
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Elizabeth Selvin
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; and Department of Epidemiology and
| | - Lawrence J Appel
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; and Department of Epidemiology and
| | | | - Josef Coresh
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; and Department of Epidemiology and Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
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Abstract
BACKGROUND In response to recent studies, a better understanding of the risks of renal complications among African American and biologically related living kidney donors is needed. METHODS We examined a database linking U.S. registry identifiers for living kidney donors (1987-2007) to billing claims from a private health insurer (2000-2007 claims) to identify renal condition diagnoses categorized by International Classification of Diseases 9th Revision coding. Cox regression with left and right censoring was used to estimate cumulative incidence of diagnoses after donation and associations (adjusted hazards ratios, aHR) with donor traits. RESULTS Among 4650 living donors, 13.1% were African American and 76.3% were white; 76.1% were first-degree relatives of their recipient. By 7 years post-donation, after adjustment for age and sex, greater proportions of African American compared with white donors had renal condition diagnoses: chronic kidney disease (12.6% vs 5.6%; aHR, 2.32; 95% confidence interval [95% CI], 1.48-3.62), proteinuria (5.7% vs 2.6%; aHR, 2.27; 95% CI, 1.32-3.89), nephrotic syndrome (1.3% vs 0.1%; aHR, 15.7; 95% CI, 2.97-83.0), and any renal condition (14.9% vs 9.0%; aHR, 1.72; 95% CI, 1.23-2.41). Although first-degree biological relationship to the recipient was not associated with renal risk, associations of African American race persisted for these conditions and included unspecified renal failure and reported disorders of kidney dysfunction after adjustment for biological donor-recipient relationship. CONCLUSIONS African Americans more commonly develop renal conditions after living kidney donation, independent of donor-recipient relationship. Continued research is needed to improve risk stratification for renal outcomes among African American living donors.
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34
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Riella LV, Sheridan AM. Testing for High-Risk APOL1 Alleles in Potential Living Kidney Donors. Am J Kidney Dis 2015; 66:396-401. [DOI: 10.1053/j.ajkd.2015.04.046] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 04/21/2015] [Indexed: 11/11/2022]
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End-stage renal disease risk in live kidney donors: what have we learned from two recent studies? Curr Opin Nephrol Hypertens 2015; 23:592-6. [PMID: 25160076 PMCID: PMC4189686 DOI: 10.1097/mnh.0000000000000063] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
PURPOSE OF REVIEW Living kidney donation improves the lives of those with kidney failure, but there are potential risks to the donor. We review two recent publications that describe the long-term risk of end-stage renal disease (ESRD) in living kidney donors. RECENT FINDINGS One study reported that the long-term risk (median follow-up 15.1 years) of ESRD was, in relative terms, 11-fold higher in living kidney donors compared to healthy nondonors, and suggested a hereditary association since all affected donors were biologically related to their recipients and the causes were predominantly immunological diseases. In a second study, we estimated that the long-term risk (median follow-up 7.6 years) of ESRD was, in relative terms, eight-fold higher in living kidney donors compared to healthy matched nondonors. In both studies, the absolute increase in the 15-year incidence of ESRD from donation was below 0.5%. There are limitations in these studies, which have raised questions about the accuracy of the estimates of risk. SUMMARY The results of these studies should be discussed with potential living kidney donors with an emphasis on the low 15-year incidence of ESRD following donation. The lifetime incidence of ESRD for donors of different age, race, and other characteristics requires further study.
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Freedman BI, Julian BA, Pastan SO, Israni AK, Schladt D, Gautreaux MD, Hauptfeld V, Bray RA, Gebel HM, Kirk AD, Gaston RS, Rogers J, Farney AC, Orlando G, Stratta RJ, Mohan S, Ma L, Langefeld CD, Hicks PJ, Palmer ND, Adams PL, Palanisamy A, Reeves-Daniel AM, Divers J. Apolipoprotein L1 gene variants in deceased organ donors are associated with renal allograft failure. Am J Transplant 2015; 15:1615-22. [PMID: 25809272 PMCID: PMC4784684 DOI: 10.1111/ajt.13223] [Citation(s) in RCA: 137] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Revised: 11/05/2014] [Accepted: 11/22/2014] [Indexed: 01/25/2023]
Abstract
Apolipoprotein L1 gene (APOL1) nephropathy variants in African American deceased kidney donors were associated with shorter renal allograft survival in a prior single-center report. APOL1 G1 and G2 variants were genotyped in newly accrued DNA samples from African American deceased donors of kidneys recovered and/or transplanted in Alabama and North Carolina. APOL1 genotypes and allograft outcomes in subsequent transplants from 55 U.S. centers were linked, adjusting for age, sex and race/ethnicity of recipients, HLA match, cold ischemia time, panel reactive antibody levels, and donor type. For 221 transplantations from kidneys recovered in Alabama, there was a statistical trend toward shorter allograft survival in recipients of two-APOL1-nephropathy-variant kidneys (hazard ratio [HR] 2.71; p = 0.06). For all 675 kidneys transplanted from donors at both centers, APOL1 genotype (HR 2.26; p = 0.001) and African American recipient race/ethnicity (HR 1.60; p = 0.03) were associated with allograft failure. Kidneys from African American deceased donors with two APOL1 nephropathy variants reproducibly associate with higher risk for allograft failure after transplantation. These findings warrant consideration of rapidly genotyping deceased African American kidney donors for APOL1 risk variants at organ recovery and incorporation of results into allocation and informed-consent processes.
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Affiliation(s)
- Barry I. Freedman
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine; Winston-Salem, NC,Center for Human Genomics & Personalized Medicine Research, Wake Forest School of Medicine; Winston-Salem, NC
| | - Bruce A. Julian
- Department of Medicine, Division of Nephrology, University of Alabama at Birmingham School of Medicine; Birmingham, AL
| | - Stephen O. Pastan
- Department of Medicine, Renal Division, Emory University School of Medicine; Atlanta, GA
| | - Ajay K. Israni
- Department of Medicine, Division of Nephrology, Hennepin County Medical Center, University of Minnesota; Minneapolis, MN,Minneapolis Medical Research Foundation; Minneapolis, MN
| | - David Schladt
- Minneapolis Medical Research Foundation; Minneapolis, MN
| | - Michael D. Gautreaux
- General Surgery & HLA Immunogenetics Lab, Wake Forest School of Medicine; Winston-Salem, NC
| | - Vera Hauptfeld
- Alabama Regional Histocompatibility Laboratory at UAB, University of Alabama at Birmingham School of Medicine; Birmingham, AL
| | - Robert A. Bray
- Department of Pathology & Lab Medicine; Emory School of Medicine; Atlanta, GA
| | - Howard M. Gebel
- Department of Pathology & Lab Medicine; Emory School of Medicine; Atlanta, GA
| | - Allan D. Kirk
- Department of General Surgery, Duke University School of Medicine; Durham, NC
| | - Robert S. Gaston
- Department of Medicine, Division of Nephrology, University of Alabama at Birmingham School of Medicine; Birmingham, AL
| | - Jeffrey Rogers
- Department of General Surgery, Wake Forest School of Medicine; Winston-Salem, NC
| | - Alan C. Farney
- Department of General Surgery, Wake Forest School of Medicine; Winston-Salem, NC
| | - Giuseppe Orlando
- Department of General Surgery, Wake Forest School of Medicine; Winston-Salem, NC
| | - Robert J. Stratta
- Department of General Surgery, Wake Forest School of Medicine; Winston-Salem, NC
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, NY
| | - Lijun Ma
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine; Winston-Salem, NC
| | - Carl D. Langefeld
- Division of Public Health Sciences, Wake Forest School of Medicine; Winston-Salem, NC
| | - Pamela J. Hicks
- Center for Human Genomics & Personalized Medicine Research, Wake Forest School of Medicine; Winston-Salem, NC
| | - Nicholette D. Palmer
- Center for Human Genomics & Personalized Medicine Research, Wake Forest School of Medicine; Winston-Salem, NC
| | - Patricia L. Adams
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine; Winston-Salem, NC
| | - Amudha Palanisamy
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine; Winston-Salem, NC
| | - Amber M. Reeves-Daniel
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine; Winston-Salem, NC
| | - Jasmin Divers
- Division of Public Health Sciences, Wake Forest School of Medicine; Winston-Salem, NC
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Rodrigue JR, Kazley AS, Mandelbrot DA, Hays R, LaPointe Rudow D, Baliga P. Living Donor Kidney Transplantation: Overcoming Disparities in Live Kidney Donation in the US--Recommendations from a Consensus Conference. Clin J Am Soc Nephrol 2015; 10:1687-95. [PMID: 25883072 DOI: 10.2215/cjn.00700115] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Despite its superior outcomes relative to chronic dialysis and deceased donor kidney transplantation, live donor kidney transplantation (LDKT) is less likely to occur in minorities, older adults, and poor patients than in those who are white, younger, and have higher household income. In addition, there is considerable geographic variability in LDKT rates. Concomitantly, in recent years, the rate of living kidney donation (LKD) has stopped increasing and is declining, after decades of consistent growth. Particularly noteworthy is the decline in LKD among black, younger, male, and lower-income adults. The Live Donor Community of Practice within the American Society of Transplantation, with financial support from 10 other organizations, held a Consensus Conference on Best Practices in Live Kidney Donation in June 2014. The purpose of this meeting was to identify LKD best practices and knowledge gaps that might influence LDKT, with a focus on patient and donor education, evaluation efficiencies, disparities, and systemic barriers to LKD. In this article, we discuss trends in LDKT/LKD and emerging novel strategies for attenuating disparities, and we offer specific recommendations for future clinical practice, education, research, and policy from the Consensus Conference Workgroup focused on disparities.
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Affiliation(s)
- James R Rodrigue
- Transplant Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Abby Swanson Kazley
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Didier A Mandelbrot
- Transplant Center, University of Wisconsin Hospital and Clinics, Madison, Wisconsin; and
| | - Rebecca Hays
- Transplant Center, University of Wisconsin Hospital and Clinics, Madison, Wisconsin; and
| | - Dianne LaPointe Rudow
- Recanati Miller Transplantation Institute, Mount Sinai Medical Center, New York, New York
| | - Prabhakar Baliga
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina;
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Rodrigue JR, Paek MJ, Egbuna O, Waterman AD, Schold JD, Pavlakis M, Mandelbrot DA. Readiness of wait-listed black patients to pursue live donor kidney transplant. Prog Transplant 2015; 24:355-61. [PMID: 25488559 DOI: 10.7182/pit2014337] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONTEXT For adults with end-stage kidney disease, live donor kidney transplant (LDKT) has better outcomes than long-term dialysis and deceased donor kidney transplant. However, black patients receive LDKT at a much lower rate than adults of any other race or ethnicity. OBJECTIVE To examine the LDKT readiness stage of black patients on the transplant waiting list and its association with LDKT knowledge, concerns, and willingness. DESIGN Cross-sectional analysis of baseline data from a randomized controlled trial to improve knowledge and reduce concerns about LDKT.Patients and Setting-One hundred fifty-two black patients on the kidney transplant waiting list at a single transplant center in the northeastern United States. MAIN OUTCOME MEASURES LDKT readiness stage, knowledge, concerns, and willingness to talk to others about living donation. RESULTS Sixty percent of patients were not considering or not yet ready to pursue LDKT, and only 11% had taken action to talk to family members or friends about the possibility of living kidney donation. Patients in later stages of LDKT readiness (ie, who had talked to others about donation or were preparing to do so) had significantly more knowledge (P<.001), fewer concerns (P=.002), and more willingness (P=.001) to talk to others about living donation than those in earlier readiness stages. CONCLUSIONS The large percentage of black patients who are in the earlier stages of LDKT readiness may account for the low rate of LDKT in this patient population at our transplant center. Innovative and tailored LDKT educational strategies for black patients are needed to help reduce racial disparities in LDKT.
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Affiliation(s)
- James R Rodrigue
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Matthew J Paek
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Ogo Egbuna
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | | | | | - Martha Pavlakis
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Didier A Mandelbrot
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
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40
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Kruzel-Davila E, Wasser WG, Aviram S, Skorecki K. APOL1 nephropathy: from gene to mechanisms of kidney injury. Nephrol Dial Transplant 2015; 31:349-58. [PMID: 25561578 DOI: 10.1093/ndt/gfu391] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 11/22/2014] [Indexed: 12/22/2022] Open
Abstract
The contribution of African ancestry to the risk of focal segmental glomerulosclerosis and chronic kidney disease has been partially explained by the recently described chromosome 22q variants in the gene apolipoprotein L1 (APOL1). The APOL1 variants appear at a high allele frequency in populations of West African ancestry as a result of apparent adaptive selection of the heterozygous state. Heterozygosity protects from infection with Trypanosoma brucei rhodesiense. This review will describe the role of the approaches in population genetics for the description of APOL1-associated nephropathies and draw inferences as to the biologic mechanisms from genetic epidemiology findings to date. Modifier loci can influence APOL1 risk for the development of kidney disease. 'Second hits', both viral and non-viral, may explain the discrepancy between the remarkably high odds ratios and the low lifetime risks of kidney disease in two allele carriers of APOL1 risk variants. Therapeutic strategies for APOL1-associated nephropathies will require the prevention and treatment of these 'second hits' and the development of drugs to protect the APOL1 downstream renal injury pathways.
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Affiliation(s)
- Etty Kruzel-Davila
- Rappaport Faculty of Medicine and Research Institute, Technion-Israel Institute of Technology, Rambam Health Care Campus, Haifa 3109601, Israel Rambam Health Care Campus, Haifa 3109601, Israel
| | - Walter G Wasser
- Rambam Health Care Campus, Haifa 3109601, Israel Mayanei HaYeshua Medical Center, Bnei Brak 51544, Israel
| | - Sharon Aviram
- Rappaport Faculty of Medicine and Research Institute, Technion-Israel Institute of Technology, Rambam Health Care Campus, Haifa 3109601, Israel
| | - Karl Skorecki
- Rappaport Faculty of Medicine and Research Institute, Technion-Israel Institute of Technology, Rambam Health Care Campus, Haifa 3109601, Israel Rambam Health Care Campus, Haifa 3109601, Israel
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Gautreaux MD, Freedman BI. Genotypic variation and outcomes in kidney transplantation: donor and recipient effects. Kidney Int 2014; 84:431-3. [PMID: 23989355 PMCID: PMC3761401 DOI: 10.1038/ki.2013.167] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The genetic composition of a donor impacts long-term allograft survival after kidney transplantation. Effects of the recipient's genetic make-up, particularly variation in immune response pathway genes, are less certain. Bay et al. reveal improved graft survival in transplant recipients with lower copy numbers of the complement 4 gene (C4) after receipt of deceased-donor kidneys. Genomics breakthroughs in nephrology and immunology will likely revolutionize the field of transplant medicine.
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Affiliation(s)
- Michael D Gautreaux
- Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina 27157-1053, USA
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The impact of APOL1, CAV1, and ABCB1 gene variants on outcomes in kidney transplantation: donor and recipient effects. Pediatr Nephrol 2014; 29:1485-92. [PMID: 23748364 PMCID: PMC3809028 DOI: 10.1007/s00467-013-2531-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Revised: 05/21/2013] [Accepted: 05/22/2013] [Indexed: 12/13/2022]
Abstract
Dramatic improvements have been seen in short-term kidney allograft survival over recent decades with introduction of more potent immunosuppressant medications and regimens. Unfortunately, improvements in long-term graft survival have lagged behind. The genomics revolution is providing new insights regarding the potential impact of kidney donor genotypes on long-term graft survival. Variation in the donor apolipoprotein L1 (APOL1), caveolin 1 (CAV1), and multi-drug resistance 1 encoding P-glycoprotein genes (ABCB1) are all associated with graft survival after kidney transplantation. Although the precise mechanisms whereby these donor gene variants confer risk for graft loss have yet to be determined, these findings provide novel opportunities for modifying interactive environmental factors and optimizing kidney allocation with the ultimate goal of improving long-term graft survival rates.
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Abstract
Marked familial aggregation of chronic kidney disease suggests that inherited factors play a major role in nephropathy susceptibility. Molecular genetics analyses have identified a number of genes reproducibly associated with a broad range of renal phenotypes. Most associations show polygenic inheritance patterns with limited effect size. In contrast, genetic association between the apolipoprotein L1 (APOL1) gene and several severe nondiabetic forms of kidney disease in African Americans approach Mendelian inheritance patterns and account for a large proportion of glomerulosclerosis in populations of African ancestry. Emerging data support an important role for APOL1 in the progression of diverse etiologies of kidney disease, in concert with requisite environmental (gene*environment) and inherited (gene*gene) interactions. This article reviews the current status of APOL1-associated nephropathy and discusses research questions under active investigation in the search for a cure for these severe and often progressive kidney diseases.
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Kofman T, Audard V, Narjoz C, Gribouval O, Matignon M, Leibler C, Desvaux D, Lang P, Grimbert P. APOL1 polymorphisms and development of CKD in an identical twin donor and recipient pair. Am J Kidney Dis 2014; 63:816-9. [PMID: 24518129 DOI: 10.1053/j.ajkd.2013.12.014] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Accepted: 12/21/2013] [Indexed: 11/11/2022]
Abstract
We report an occurrence of progressive loss of transplant function and ultimately transplant failure after living related kidney transplantation involving monozygotic twin brothers of Afro-Caribbean origin who were both heterozygous for the G1 and G2 kidney disease risk alleles in the APOL1 gene, which encodes apolipoprotein L-I. A 21-year-old man with end-stage kidney disease of unknown cause received a kidney from his brother, who was confirmed as a monozygotic twin by microsatellite analysis. Thirty months after transplantation, the patient presented with proteinuria and decreased estimated glomerular filtration rate; a biopsy of the transplant showed typical focal segmental glomerulosclerosis lesions. He received steroid therapy, but progressed to kidney failure 5 years later. The twin brother had normal kidney function without proteinuria at the time of transplantation; however, 7 years later, he was found to have decreased estimated glomerular filtration rate (40mL/min/1.73m(2)) and proteinuria (protein excretion of 2.5g/d). APOL1 genotyping revealed that both donor and recipient were heterozygous for the G1 and G2 alleles. This case is in stark contrast to the expected course of kidney transplantation in identical twins and suggests a role for APOL1 polymorphisms in both the donor and recipient.
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Affiliation(s)
- Tomek Kofman
- Service de Néphrologie et Transplantation, Hôpital Henri Mondor, Centre de référence maladie rare Syndrome Néphrotique Idiopathique, Institut Francilien de recherche en Néphrologie et Transplantation (IFRNT), INSERM U955, Université Paris Est Créteil, APHP (Assistance Publique-Hôpitaux de Paris, Créteil), Créteil, France.
| | - Vincent Audard
- Service de Néphrologie et Transplantation, Hôpital Henri Mondor, Centre de référence maladie rare Syndrome Néphrotique Idiopathique, Institut Francilien de recherche en Néphrologie et Transplantation (IFRNT), INSERM U955, Université Paris Est Créteil, APHP (Assistance Publique-Hôpitaux de Paris, Créteil), Créteil, France
| | - Céline Narjoz
- Université Paris Descartes, INSERM UMR-S 775, APHP, Hôpital Européen Georges Pompidou, Service de Biochimie, Unité Fonctionnelle de Pharmacogénétique et Oncologie Moléculaire, Paris, France
| | - Olivier Gribouval
- INSERM U983, Hôpital Necker-Enfants Malades, Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Institut Imagine, Paris, France
| | - Marie Matignon
- Service de Néphrologie et Transplantation, Hôpital Henri Mondor, Centre de référence maladie rare Syndrome Néphrotique Idiopathique, Institut Francilien de recherche en Néphrologie et Transplantation (IFRNT), INSERM U955, Université Paris Est Créteil, APHP (Assistance Publique-Hôpitaux de Paris, Créteil), Créteil, France
| | - Claire Leibler
- Service de Néphrologie et Transplantation, Hôpital Henri Mondor, Centre de référence maladie rare Syndrome Néphrotique Idiopathique, Institut Francilien de recherche en Néphrologie et Transplantation (IFRNT), INSERM U955, Université Paris Est Créteil, APHP (Assistance Publique-Hôpitaux de Paris, Créteil), Créteil, France
| | - Dominique Desvaux
- Service de Néphrologie et Transplantation, Hôpital Henri Mondor, Centre de référence maladie rare Syndrome Néphrotique Idiopathique, Institut Francilien de recherche en Néphrologie et Transplantation (IFRNT), INSERM U955, Université Paris Est Créteil, APHP (Assistance Publique-Hôpitaux de Paris, Créteil), Créteil, France
| | - Philippe Lang
- Service de Néphrologie et Transplantation, Hôpital Henri Mondor, Centre de référence maladie rare Syndrome Néphrotique Idiopathique, Institut Francilien de recherche en Néphrologie et Transplantation (IFRNT), INSERM U955, Université Paris Est Créteil, APHP (Assistance Publique-Hôpitaux de Paris, Créteil), Créteil, France
| | - Philippe Grimbert
- Service de Néphrologie et Transplantation, Hôpital Henri Mondor, Centre de référence maladie rare Syndrome Néphrotique Idiopathique, Institut Francilien de recherche en Néphrologie et Transplantation (IFRNT), INSERM U955, Université Paris Est Créteil, APHP (Assistance Publique-Hôpitaux de Paris, Créteil), Créteil, France
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Freedman BI, Divers J, Palmer ND. Population ancestry and genetic risk for diabetes and kidney, cardiovascular, and bone disease: modifiable environmental factors may produce the cures. Am J Kidney Dis 2013; 62:1165-75. [PMID: 23896482 PMCID: PMC3840048 DOI: 10.1053/j.ajkd.2013.05.024] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Accepted: 05/24/2013] [Indexed: 12/22/2022]
Abstract
Variable rates of disease observed between members of different continental population groups may be mediated by inherited factors, environmental exposures, or their combination. This article provides evidence in support of differential allele frequency distributions that underlie the higher rates of nondiabetic kidney disease in the focal segmental glomerulosclerosis spectrum of disease and lower rates of coronary artery calcified atherosclerotic plaque and osteoporosis in populations of African ancestry. With recognition that these and other common complex diseases are affected by biological factors comes the realization that targeted manipulation of environmental exposures and pharmacologic treatments will have different effects based on genotype. The present era of precision medicine will couple one's genetic makeup with specific therapies to reduce rates of disease based on the presence of disease-specific alleles.
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Affiliation(s)
- Barry I Freedman
- Department of Internal Medicine-Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC; Center for Human Genomics and Personalized Medicine Research, Wake Forest School of Medicine, Winston-Salem, NC.
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Lentine KL, Segev DL. Health outcomes among non-Caucasian living kidney donors: knowns and unknowns. Transpl Int 2013; 26:853-64. [DOI: 10.1111/tri.12088] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Revised: 12/14/2012] [Accepted: 02/15/2013] [Indexed: 11/29/2022]
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Kasiske BL, Anderson-Haag T, Ibrahim HN, Pesavento TE, Weir MR, Nogueira JM, Cosio FG, Kraus ES, Rabb HH, Kalil RS, Posselt AA, Kimmel PL, Steffes MW. A prospective controlled study of kidney donors: baseline and 6-month follow-up. Am J Kidney Dis 2013; 62:577-86. [PMID: 23523239 DOI: 10.1053/j.ajkd.2013.01.027] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Accepted: 01/18/2013] [Indexed: 11/11/2022]
Abstract
BACKGROUND Most previous studies of living kidney donors have been retrospective and have lacked suitable healthy controls. Needed are prospective controlled studies to better understand the effects of a mild reduction in kidney function from kidney donation in otherwise healthy individuals. STUDY DESIGN Prospective, controlled, observational cohort study. SETTING & PARTICIPANTS Consecutive patients approved for donation at 8 transplant centers in the United States were asked to participate. For every donor enrolled, an equally healthy control with 2 kidneys who theoretically would have been suitable to donate a kidney also was enrolled. PREDICTOR Kidney donation. MEASUREMENTS At baseline predonation and at 6 months after donation, medical history, vital signs, measured (iohexol) glomerular filtration rate, and other measurements were collected. There were 201 donors and 198 controls who completed both baseline and 6-month visits and form the basis of this report. RESULTS Compared with controls, donors had 28% lower glomerular filtration rates at 6 months (94.6 ± 15.1 [SD] vs 67.6 ± 10.1 mL/min/1.73 m(2); P < 0.001), associated with 23% greater parathyroid hormone (42.8 ± 15.6 vs 52.7 ± 20.9 pg/mL; P < 0.001), 5.4% lower serum phosphate (3.5 ± 0.5 vs 3.3 ± 0.5 mg/dL; P < 0.001), 3.7% lower hemoglobin (13.6 ± 1.4 vs 13.1 ± 1.2 g/dL; P < 0.001), 8.2% greater uric acid (4.9 ± 1.2 vs 5.3 ± 1.1 mg/dL; P < 0.001), 24% greater homocysteine (1.2 ± 0.3 vs 1.5 ± 0.4 mg/L; P < 0.001), and 1.5% lower high-density lipoprotein cholesterol (54.9 ± 16.4 vs 54.1 ± 13.9 mg/dL; P = 0.03) levels. There were no differences in albumin-creatinine ratios (5.0 [IQR, 4.0-6.6] vs 5.0 [IQR, 3.3-5.4] mg/g; P = 0.5), office blood pressures, or glucose homeostasis. LIMITATIONS Short duration of follow-up and possible bias resulting from an inability to screen controls with kidney and vascular imaging performed in donors. CONCLUSIONS Kidney donors have some, but not all, abnormalities typically associated with mild chronic kidney disease 6 months after donation. Additional follow-up is warranted.
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Affiliation(s)
- Bertram L Kasiske
- Department of Medicine, Hennepin County Medical Center, Minneapolis, MN 55415, USA.
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APOL1 null alleles from a rural village in India do not correlate with glomerulosclerosis. PLoS One 2012; 7:e51546. [PMID: 23300552 PMCID: PMC3530541 DOI: 10.1371/journal.pone.0051546] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Accepted: 11/02/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Among African-Americans, genome wide association revealed a strong correlation between the G1 and G2 alleles of APOL1 (apolipoproteinL1, also called trypanolytic factor) and kidney diseases including focal and segmental glomerulosclerosis, HIV-associated nephropathy and hypertensive nephrosclerosis. In the prevailing hypothesis, heterozygous APOL1 G1 and G2 alleles increase resistance against Trypanosoma that cause African sleeping sickness, resulting in positive selection of these alleles, but when homozygous the G1 and G2 alleles predispose to glomerulosclerosis. While efforts are underway to screen patients for G1 and G2 alleles and to better understand "APOL1 glomerulopathy," no data prove that these APOL1 sequence variants cause glomerulosclerosis. G1 and G2 correlate best with glomerulosclerosis as recessive alleles, which suggests a loss of function mutation for which proof of causality is commonly tested with homozygous null alleles. This test cannot be performed in rodents as the APOL gene cluster evolved only in primates. However, there is a homozygous APOL1 null human being who lives in a village in rural India. This individual and his family offer a unique opportunity to test causality between APOL1 null alleles and glomerulosclerosis. METHODS AND FINDINGS We obtained clinical data, blood and urine from this APOL1 null patient and 50 related villagers. Based on measurements of blood pressure, BUN, creatinine, albuminuria, genotyping and immunoblotting, this APOL1 null individual does not have glomerulosclerosis, nor do his relatives who carry APOL1 null alleles. CONCLUSIONS This small study cannot provide definitive conclusions but the absence of glomerulosclerosis in this unique population is consistent with the possibility that African-American glomerulosclerosis is caused, not by loss of APOL1 function, but by other mechanisms including a subtle gain of function or by the "genetic hitchhiking" of deleterious mutations in a gene linked to APOL1 G1 and G2.
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Pondrom S. The AJT Report: news and issues that affect organ and tissue transplantation. Genetic factor may limitkidney donation. Am J Transplant 2012; 12:2865-6. [PMID: 23107266 DOI: 10.1111/j.1600-6143.2012.04329.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Recent studies have shown that African Americans have genetic variants that appear to incrementally increase their risk for ESRD. This month, "The AJT Report" explores the dilemma now facing transplant professionals: Should African American potential live kidney donors be prospectively genotyped and warned about possible associations between genetic background and outcomes? Also this month, "The AJT Report" checks in on the status of some living donor outcomes research.
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Cooper M, Kramer A, Barth R, Phelan M. Living kidney donor relationship in Caucasian and African American populations and implications for targeted donor education programs. Clin Transplant 2012; 27:32-6. [PMID: 22775242 DOI: 10.1111/j.1399-0012.2012.01685.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2012] [Indexed: 11/29/2022]
Abstract
PURPOSE The opportunities for living kidney donation vary greatly among socioeconomic and racial groups. We reviewed our series of living donors to evaluate donor relationships in various groups. MATERIALS AND METHODS Donor and recipient records for 1000 patients were reviewed. An additional 857 records of potential recipients presenting with a donor were analyzed. We compared the relationship of the recipient to initial donor and individual who underwent nephrectomy. RESULTS There were 693 CC and 263 AA live kidney donors. In the AA population donors were first-degree 71%, second-degree 10%, and unrelated 19%. In the CC population donors were first-degree 57%, second-degree 6%, and unrelated 37% (p < 0.0001 for unrelated CC vs. AA). Spousal donation is more common in CC donors (13%) than AA donors (6%), p = 0.001. Donation from child to parent is more common in AA (33%) than CC donors (15%), p < 0.0001. AA recipients predominantly identified a child as a donor in 63% and 48% were cleared for donation. In contrast, 69% of CC recipients identified a spouse as a donor yet only 23% became donors, p < 0.001 and p < 0.001. CONCLUSIONS There is a higher incidence of unrelated donors in the caucasian population, vs. first degree relatives often being living donors in the AA population.
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Affiliation(s)
- Matthew Cooper
- Division of Transplantation, University of Maryland Medical System, Baltimore, MD, USA.
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