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Pol SJ, Selkirk EK, Damer A, Mucsi I, Abbey S, Edwards B, Fung K, Gill J, Neves P, Ng SY, Parekh RS, Wright L, Wu M, Anthony SJ. "Weighing the Pros and Cons of Everything": A Qualitative Descriptive Study Exploring Perspectives About Living Donor Kidney Transplantation From Parents of Chinese Canadian Pediatric Patients With Chronic Kidney Disease. Can J Kidney Health Dis 2024; 11:20543581241249872. [PMID: 38737938 PMCID: PMC11088299 DOI: 10.1177/20543581241249872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 03/21/2024] [Indexed: 05/14/2024] Open
Abstract
Background As of 2021, more than 6000 children and youth in Canada were living with end-stage kidney disease (ESKD), for which kidney transplantation is considered the preferred treatment by health professionals. Research shows that living donor kidney transplantation (LDKT) has superior allograft and recipient survival compared to deceased donor kidney transplantation (DDKT). However, in a pediatric setting, the choice of LDKT or DDKT is a summative consideration of factors weighed carefully by the patient's family, health care team, and patient. Decision-making surrounding transplantation may be more complex for racial and ethnic minorities as culturally specific values and beliefs are interwoven within dominant understandings and concepts of health and accepted models of health care. For example, Chinese Canadians have an increased risk of ESKD, yet reduced access to LDKT compared to White patients, despite being the largest visible minority population in Canada. Objective The objective of this qualitative study is to deepen our understandings of the decision-making process surrounding DDKT versus LDKT among parents of Chinese Canadian pediatric patients with chronic kidney disease (CKD). Design Qualitative descriptive study design. Setting The Nephrology Program at The Hospital for Sick Children in Toronto, Canada. Participants Caregivers of Chinese Canadian patients with CKD, 18 years of age or older, and who spoke English, Cantonese, or Mandarin. Methods One-on-one, semistructured interviews were conducted virtually, by a member of the research team and were audio-recorded and transcribed verbatim. Thematic analysis was used to explore participants' shared experience. Results Seven interviews were conducted with 6 mothers and 1 father of 6 Chinese Canadian pediatric patients with CKD: 4 patients had undergone a kidney transplant, and 2 were not yet listed for transplant. Analysis of data highlighted that cultural influences affected whether parents shared with others about their child's illness and experience. The cultural understanding that it is inappropriate to burden others contributed to the creation of an isolating experience for participants. Cultural influences also impacted whether parents asked others to be a living donor as participants articulated this would place a physical burden on the living donor (e.g., potential risk to their health) and an emotional burden on the participant as they would be indebted to a willing donor. Ultimately, parents' decision to choose DDKT or LDKT for their patient-child was a result of evaluating both options carefully and within an understanding that the ideal treatment choice reflected what was best for all family members. Limitations Findings reflect experiences of a small sample from a single recruitment site which may limit transferability. Conclusions Parents in this study felt that they had access to the necessary evidence-based information to make an informed decision about the choice of DDKT versus LDKT for their child. Participant narratives described feeling isolated within cultural communities of family and friends and participants' suggestion of benefiting from increased support may guide future research directions. Practitioners can offer direct and indirect support to families, with recognition of the importance of cultural values and family-centered care on decision-making within families. Opportunities are needed for accessible, virtual social support platforms to increase parental feelings of culturally mediated peer support from parents who share similar experiences.
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Affiliation(s)
- Sarah J. Pol
- Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada
| | - Enid K. Selkirk
- Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada
| | - Alameen Damer
- Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada
| | - Istvan Mucsi
- Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
- Division of Nephrology, University of Toronto, ON, Canada
| | - Susan Abbey
- Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
- Centre for Mental Health, University Health Network, Toronto, ON, Canada
- Temerty Faculty of Medicine, University of Toronto, ON, Canada
| | - Beth Edwards
- Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Kenneth Fung
- Department of Psychiatry, University of Toronto, ON, Canada
| | - Jagbir Gill
- Division of Nephrology, Faculty of Medicine, The University of British Columbia, Vancouver, Canada
- Kidney Transplant Program, St. Paul’s Hospital, Vancouver, BC, Canada
| | - Paula Neves
- Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Suk Yin Ng
- Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Rulan S. Parekh
- Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Medicine, Women’s College Hospital, Toronto, ON, Canada
- Department of Paediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Linda Wright
- Department of Surgery, University of Toronto, ON, Canada
| | - Minglin Wu
- Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Samantha J. Anthony
- Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada
- Factor-Inwentash Faculty of Social Work, University of Toronto, ON, Canada
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Riar S, Srivastava T, George R. Transition of Care in Children with Chronic Kidney Disease, Dialysis, and Transplantation. Indian J Pediatr 2023; 90:1237-1244. [PMID: 37291387 DOI: 10.1007/s12098-023-04629-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 04/18/2023] [Indexed: 06/10/2023]
Abstract
Improvement in management of pediatric renal disorders has led to patient survival rates of 85-90%, increasing the number of adolescent and young adult (AYA) patients with childhood onset chronic kidney disease (CKD) transitioning to adult care settings. Pediatric CKD patients differ from adults with CKD in view of early onset of disease (sometimes with fetal onset), different disease spectrum, the potential effect of CKD on neurodevelopment, and substantial involvement of parents in medical decision making. In addition to the usual challenges of emerging adulthood (graduation from school to work, independent living, peak in impulsivity and risk-taking behaviors), young adults with pediatric CKD need to learn to manage a serious medical condition independently. In kidney transplant patients, regardless of the age at transplantation, graft failure rates are higher during adolescence and young adulthood than at any other age. All pediatric CKD patients must move from a pediatric to adult-focused settings and this transition is a longitudinal process requiring collaboration and interactions of AYA patients, their families, providers, health care environment and agencies. Consensus guidelines have provided recommendations to pediatric and adult renal teams to enable successful transition. Suboptimal transition is a risk factor for poor adherence to treatment and unfavorable health outcomes. The authors discuss the process of transition as it applies to pediatric CKD patients and review challenges faced by patients/families, pediatric and adult nephrology teams. They provide some suggestions and available tools to optimize the transition of pediatric CKD patients to adult-oriented care.
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Affiliation(s)
- Sandeep Riar
- Division of Pediatric Nephrology, Emory University and Children's Healthcare of Atlanta, 2015 Uppergate Drive, Atlanta, GA, 30322, USA.
| | - Tarak Srivastava
- Section of Nephrology, Children's Mercy Hospital and University of Missouri at Kansas City, Kansas City, MO, USA
- Midwest Veterans' Biomedical Research Foundation (MVBRF), Kansas City, MO, USA
- Department of Oral and Craniofacial Sciences, University of Missouri at Kansas City - School of Dentistry, Kansas City, MO, USA
| | - Roshan George
- Division of Pediatric Nephrology, Emory University and Children's Healthcare of Atlanta, 2015 Uppergate Drive, Atlanta, GA, 30322, USA
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Neves CIMR, Leal ARGC, Santos LSD, Rodrigues LMA, Ferreira CDCC, Ferreira CMDSG, Romãozinho CPDRDM, Figueiredo AJDC. Pediatric Kidney Transplantation-Living or Deceased Donor? Transplant Proc 2023; 55:1555-1560. [PMID: 37419736 DOI: 10.1016/j.transproceed.2023.04.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 04/14/2023] [Indexed: 07/09/2023]
Abstract
BACKGROUND Kidney transplantation is ideal for children and adolescents with chronic end-stage renal disease because it offers better growth, development, and quality of life. Donor choice is vitally important in this age group, given the long life expectancy of these patients. METHODS A retrospective analysis of pediatric patients (<18 years) who underwent kidney transplantation from January 1999 to December/2018 was performed. Short- and long-term outcomes were compared between living and deceased donor transplants. RESULTS We included 59 pediatric kidney transplant recipients, 12 from a living donor and 47 from a deceased donor. Thirty-six (61.0%) patients were boys, and 5 (8.5%) had a retransplant. There were no differences between groups on sex, race, and weight of the recipient and donor, as well as the age and the etiology of the recipient's primary disease. Most recipients received induction immunosuppression with basiliximab and maintenance with triple therapy, with no differences between groups. Living donor transplants were mostly pre-emptive (58.3% vs 4.3%, P < .001) and had fewer HLA mismatches (≤3: 90.9% vs 13.0%, P < .001), older donors (38.4 vs 24.3 years, P < .001) and shorter hospital stays (8.8 vs 14.1 days, P = .004). There were no statistically significant differences regarding medical-surgical complications and graft or patient survival. However, we found that at 13 years post-transplant 91.7% of the living donor grafts were functioning vs 72.3% of the deceased donor grafts. CONCLUSION Our experience points out that a living donor graft in pediatric patients is associated with a higher probability of pre-emptive transplant, shorter hospital stay, greater HLA compatibility, and increased graft survival.
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Affiliation(s)
| | - Ana Rita Gomes Carlos Leal
- Department of Nephrology, Hospital and University Center of Coimbra, Coimbra, Portugal and Medical School of Coimbra University, Coimbra, Portugal
| | - Lídia Simões Dos Santos
- Department of Nephrology, Hospital and University Center of Coimbra, Coimbra, Portugal and Medical School of Coimbra University, Coimbra, Portugal
| | - Luís Miguel Amaral Rodrigues
- Department of Nephrology, Hospital and University Center of Coimbra, Coimbra, Portugal and Medical School of Coimbra University, Coimbra, Portugal
| | | | | | | | - Arnaldo José De Castro Figueiredo
- Department of Urology and Renal Transplantation, Hospital and University Center of Coimbra, Coimbra, Portugal and Medical School of Coimbra University, Coimbra, Portugal
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Matsuda-Abedini M, Marks SD, Foster BJ. Transition of young adult kidney transplant recipients. Pediatr Nephrol 2023; 38:383-390. [PMID: 35501520 DOI: 10.1007/s00467-022-05582-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 04/03/2022] [Accepted: 04/04/2022] [Indexed: 01/10/2023]
Abstract
Survival of pediatric kidney transplant recipients has improved over the past six decades. However, adolescents and young adults still have the highest graft failure rates of any age group. There is a growing need for well-designed transition programs to ensure the successful integration of young adults into adult society with eventual transfer of care and management in adult transplant centers. In this review, we discuss the risk factors contributing to the high risk of kidney graft failure observed between 17 and 24 years of age, including the role of transfer from pediatric to adult care. We also address the unique challenges of adolescents with kidney transplant: the impact of chronic kidney disease on neurocognition, age-related changes in immune activity, and suboptimal adherence during the transition process. We then describe strategies to mitigate these risks by designing developmentally appropriate transition programs, and review the evidence supporting the benefits of well-designed multidisciplinary transition programs.
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Affiliation(s)
- Mina Matsuda-Abedini
- Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada.
| | - Stephen D Marks
- NIHR Great Ormond Street Hospital Biomedical Research Centre, University College London Great Ormond Street Institute of Child Health, London, UK.,Department of Paediatric Nephrology, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Bethany J Foster
- Department of Pediatrics, McGill University, Montreal, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada.,Research Institute of the McGill University Health Centre, McGill University, Montreal, Canada
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Seeking Standardized Definitions for HLA-incompatible Kidney Transplants: A Systematic Review. Transplantation 2023; 107:231-253. [PMID: 35915547 DOI: 10.1097/tp.0000000000004262] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND There is no standard definition for "HLA incompatible" transplants. For the first time, we systematically assessed how HLA incompatibility was defined in contemporary peer-reviewed publications and its prognostic implication to transplant outcomes. METHODS We combined 2 independent searches of MEDLINE, EMBASE, and the Cochrane Library from 2015 to 2019. Content-expert reviewers screened for original research on outcomes of HLA-incompatible transplants (defined as allele or molecular mismatch and solid-phase or cell-based assays). We ascertained the completeness of reporting on a predefined set of variables assessing HLA incompatibility, therapies, and outcomes. Given significant heterogeneity, we conducted narrative synthesis and assessed risk of bias in studies examining the association between death-censored graft failure and HLA incompatibility. RESULTS Of 6656 screened articles, 163 evaluated transplant outcomes by HLA incompatibility. Most articles reported on cytotoxic/flow T-cell crossmatches (n = 98). Molecular genotypes were reported for selected loci at the allele-group level. Sixteen articles reported on epitope compatibility. Pretransplant donor-specific HLA antibodies were often considered (n = 143); yet there was heterogeneity in sample handling, assay procedure, and incomplete reporting on donor-specific HLA antibodies assignment. Induction (n = 129) and maintenance immunosuppression (n = 140) were frequently mentioned but less so rejection treatment (n = 72) and desensitization (n = 70). Studies assessing death-censored graft failure risk by HLA incompatibility were vulnerable to bias in the participant, predictor, and analysis domains. CONCLUSIONS Optimization of transplant outcomes and personalized care depends on accurate HLA compatibility assessment. Reporting on a standard set of variables will help assess generalizability of research, allow knowledge synthesis, and facilitate international collaboration in clinical trials.
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