1
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Yu M, King KL, Maclay LM, Husain SA, Schold JD, Mohan S. Incomplete reporting of clinically significant acute rejection episodes in the national kidney transplant registry. Am J Transplant 2024:S1600-6135(24)00277-6. [PMID: 38636806 DOI: 10.1016/j.ajt.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 04/09/2024] [Accepted: 04/11/2024] [Indexed: 04/20/2024]
Abstract
Administrative claims data could provide a unique opportunity to identify acute rejection (AR) events using specific antirejection medications and to validate rejected data reported to the Organ Procurement and Transplantation Network. This retrospective cohort study examined differences in registry-reported events and those identified using claims data among adult kidney transplant recipients from 2012 to 2017 using Standard Analysis Files from the US Renal Data System. Rejection rates, survival estimates, and center-level differences were assessed using each approach. Among 45 880 first-time kidney transplant recipients, we identified 3841 AR events within 12 months of transplant reported by centers in the registry; claims data yielded 2945 events. Of all events occurring within 12 months of transplant, 48.5% were reported using registry only, 32.9% were identified using claims only, and 18.6% were identified using both approaches. A 3-year death-censored graft survival probability was 90.0%, 88.4%, and 81.2% (P < .001) for ARs identified using registry only, claims data only, and both approaches, respectively. The large discordance between registry-reported and claims-based events suggests incomplete and potentially inaccurate reporting of events in the Organ Procurement Transplant Network registry. These findings have important implications for analyses that use AR data and underscore the need for improved capture of clinically meaningful events.
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Affiliation(s)
- Miko Yu
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA; Columbia University Renal Epidemiology Group, New York, New York, USA
| | - Kristen L King
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA; Columbia University Renal Epidemiology Group, New York, New York, USA
| | - Lindsey M Maclay
- Columbia University Renal Epidemiology Group, New York, New York, USA
| | - S Ali Husain
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA; Columbia University Renal Epidemiology Group, New York, New York, USA
| | - Jesse D Schold
- Department of Surgery, University of Colorado - Anschutz Medical Campus, Aurora, Colorado, USA; Department of Epidemiology, School of Public Health, University of Colorado - Anschutz Medical Campus, Aurora, Colorado, USA
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA; Columbia University Renal Epidemiology Group, New York, New York, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA.
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2
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Garg AX, Arnold JB, Cuerden M, Dipchand C, Feldman LS, Gill JS, Karpinski M, Klarenbach S, Knoll GA, Lok C, Miller M, Monroy-Cuadros M, Nguan C, Prasad GVR, Sontrop JM, Storsley L, Boudville N. The Living Kidney Donor Safety Study: Protocol of a Prospective Cohort Study. Can J Kidney Health Dis 2022; 9:20543581221129442. [PMID: 36325263 PMCID: PMC9619271 DOI: 10.1177/20543581221129442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 08/11/2022] [Indexed: 11/14/2022] Open
Abstract
Background Living kidney donation is considered generally safe in healthy individuals; however, there is a need to better understand the long-term effects of donation on blood pressure and kidney function. Objectives To determine the risk of hypertension in healthy, normotensive adults who donate a kidney compared with healthy, normotensive non-donors with similar indicators of baseline health. We will also compare the 2 groups on the rate of decline in kidney function, the risk of albuminuria, and changes in health-related quality of life. Design Participants and Setting Prospective cohort study of 1042 living kidney donors recruited before surgery from 17 transplant centers (12 in Canada and 5 in Australia) between 2004 and 2014. Non-donor participants (n = 396) included relatives or friends of the donor, or donor candidates who were ineligible to donate due to blood group or cross-match incompatibility. Follow-up will continue until 2021, and the main analysis will be performed in 2022. The anticipated median (25th, 75th percentile, maximum) follow-up time after donation is 7 years (6, 8, 15). Measurements Donors and non-donors completed the same schedule of measurements at baseline and follow-up (non-donors were assigned a simulated nephrectomy date). Annual measurements were obtained for blood pressure, estimated glomerular filtration rate (eGFR), albuminuria, patient-reported health-related quality of life, and general health. Outcomes Incident hypertension (a systolic/diastolic blood pressure ≥ 140/90 mm Hg or receipt of anti-hypertensive medication) will be adjudicated by a physician blinded to the participant's donation status. We will assess the rate of change in eGFR starting from 12 months after the nephrectomy date and the proportion who develop an albumin-to-creatinine ratio ≥3 mg/mmol (≥30 mg/g) in follow-up. Health-related quality of life will be assessed using the 36-item RAND health survey and the Beck Anxiety and Depression inventories. Limitations Donation-attributable hypertension may not manifest until decades after donation. Conclusion This prospective cohort study will estimate the attributable risk of hypertension and other health outcomes after living kidney donation.
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Affiliation(s)
- Amit X. Garg
- Victoria Hospital, London Health Sciences Centre, ON, Canada,Amit X. Garg, Victoria Hospital, London Health Sciences Centre, 800 Commissioners Road East, ELL-200, London, ON N6A 5W9, Canada.
| | | | - Meaghan Cuerden
- Victoria Hospital, London Health Sciences Centre, ON, Canada
| | | | | | - John S. Gill
- The University of British Columbia, Vancouver, Canada
| | | | | | - Greg A. Knoll
- Department of Nephrology, Department of Medicine, The Ottawa Hospital and University of Ottawa, ON, Canada
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3
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Flaig C, Humar A, Kirshner E, Hughes C, Ganesh S, Tevar A, Steel JL. Post-operative outcomes in anonymous living liver donors: What motivates individuals to donate to strangers. Clin Transplant 2021; 35:e14438. [PMID: 34292636 DOI: 10.1111/ctr.14438] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 07/17/2021] [Accepted: 07/19/2021] [Indexed: 11/29/2022]
Abstract
Anonymous living donor liver transplantation (LDLT) is a strategy to address the shortage of available transplantable livers; however, few studies have been conducted on this population. The objective of this study was to describe the motivations and medical, psychosocial, and financial outcomes of anonymous living liver donors. Between 2010-2019, 116 anonymous living liver donors were evaluated, 59 (51.7%) of whom proceeded to surgery. A subset of 21 anonymous donors were matched to biologically/emotionally related donors according to age, gender, race, and duration since surgery. A medical chart review and post-surgical interviews were performed to assess medical and financial outcomes. The primary motivation for donors was an unselfish desire to help others (43, 72.9%). A total of 13 (22%) anonymous donors experienced complications. Of these, 7 (11.9%) were grade I Clavien-Dindo classification, 5 (8.5%) grade II, and 1 was grade III (1.7%); and no patients had grade IV-V Clavien-Dindo complications. Increased anxiety was reported by 3 (5.1%) donors, and one donor reported clinical levels of depression (1.7%). Within the matched controls, anonymous donors were not significantly different to biologically/emotionally related donors with regard to surgical complications, psychosocial, or financial outcomes. Allowing a greater number of anonymous donors may facilitate the reduction of the waitlist for liver transplant candidates. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Carly Flaig
- University of Pittsburgh School of Medicine Department of Surgery.,University of Pittsburgh Department of Psychology
| | - Abhinav Humar
- University of Pittsburgh School of Medicine Department of Surgery
| | - Emily Kirshner
- University of Pittsburgh School of Medicine Department of Surgery
| | | | - Swaytha Ganesh
- University of Pittsburgh School of Medicine Department of Surgery
| | - Amit Tevar
- University of Pittsburgh School of Medicine Department of Surgery
| | - Jennifer L Steel
- University of Pittsburgh School of Medicine Department of Surgery.,University of Pittsburgh Department of Psychology.,University of Pittsburgh School of Medicine Department of Psychiatry
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4
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Survival in Living Kidney Donors: An Australian and New Zealand Cohort Study Using Data Linkage. Transplant Direct 2020; 6:e533. [PMID: 32195324 PMCID: PMC7056283 DOI: 10.1097/txd.0000000000000975] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 12/06/2019] [Indexed: 11/27/2022] Open
Abstract
Supplemental Digital Content is available in the text. Background. Living kidney donors are a highly selected healthy population expected to have high survival postdonation, but mortality studies are limited. Our study aimed to compare mortality in living kidney donors with the general population in Australia and New Zealand, hypothesizing that donor survival would exceed average survival. Methods. All living kidney donors in Australia, 2004–2013, and New Zealand, 2004–2012, from the Australian and New Zealand Living Kidney Donor Registry were included. We ascertained primary cause of death from data linkage with national death registers. Standardized mortality ratios and relative survival were estimated, matching on age, sex, calendar year, and country. Results. Among 3253 living kidney donors, there were 32 deaths over 20 331 person-years, with median follow-up 6.2 years [interquartile range: 3.9–8.4]. Only 25 donors had diabetes-fasting blood sugar level predonation, of which 3 had impaired glucose tolerance. At discharge, the median creatinine was 108 µmol/L and estimated glomerular filtration rate was 58 mL/min/1.72 m2. Four deaths occurred in the first year: 2 from immediate complications of donation, and 2 from unrelated accidental causes. The leading cause of death was cancer (n = 16). The crude mortality rate was 157 (95% confidence interval [CI], 111-222)/100 000 person-y, and the standardized mortality ratio was 0.33 (95% CI, 0.24-0.47). The 5-year cumulative relative survival was 1.019 (95% CI, 1.014-1.021), confirming that the survival probability in living kidney donors was 2% higher relative to the general population. Conclusions. As expected, mortality in living kidney donors was substantially lower than the general population and is reassuring for potential donor counseling. The Living Donor Registry only captured a third of the deaths, highlighting the benefit of data linkage to national death registries in the long-term follow-up of living kidney donors.
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5
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Eno AK, Ruck JM, Van Pilsum Rasmussen SE, Waldram MM, Thomas AG, Purnell TS, Garonzik Wang JM, Massie AB, Al Almmary F, Cooper LM, Segev DL, Levan MA, Henderson ML. Perspectives on implementing mobile health technology for living kidney donor follow-up: In-depth interviews with transplant providers. Clin Transplant 2019; 33:e13637. [PMID: 31194892 PMCID: PMC6690770 DOI: 10.1111/ctr.13637] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 05/21/2019] [Accepted: 06/07/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND United States transplant centers are required to report follow-up data for living kidney donors for 2 years post-donation. However, living kidney donor (LKD) follow-up is often incomplete. Mobile health (mHealth) technologies could ease data collection burden but have not yet been explored in this context. METHODS We conducted semi-structured in-depth interviews with a convenience sample of 21 transplant providers and thought leaders about challenges in LKD follow-up, and the potential role of mHealth in overcoming these challenges. RESULTS Participants reported challenges conveying the importance of follow-up to LKDs, limited data from international/out-of-town LKDs, and inadequate staffing. They believed the 2-year requirement was insufficient, but expressed difficulty engaging LKDs for even this short time and inadequate resources for longer-term follow-up. Participants believed an mHealth system for post-donation follow-up could benefit LKDs (by simplifying communication/tasks and improving donor engagement) and transplant centers (by streamlining communication and decreasing workforce burden). Concerns included cost, learning curves, security/privacy, patient language/socioeconomic barriers, and older donor comfort with mHealth technology. CONCLUSIONS Transplant providers felt that mHealth technology could improve LKD follow-up and help centers meet reporting thresholds. However, designing a secure, easy to use, and cost-effective system remains challenging.
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Affiliation(s)
- Ann K Eno
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jessica M Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Madeleine M Waldram
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alvin G Thomas
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina
| | - Tanjala S Purnell
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland
- Department of Health Behavior and Society, Johns Hopkins School of Public Health, Baltimore, Maryland
- Johns Hopkins Center for Health Equity, Johns Hopkins University, Baltimore, Maryland
| | | | - Allan B Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Fawaz Al Almmary
- Division of Nephrology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Lisa M Cooper
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland
- Department of Health Behavior and Society, Johns Hopkins School of Public Health, Baltimore, Maryland
- Johns Hopkins Center for Health Equity, Johns Hopkins University, Baltimore, Maryland
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland
- Department of Acute and Chronic Care, Johns Hopkins School of Nursing, Baltimore, Maryland
| | | | - Macey L Henderson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Acute and Chronic Care, Johns Hopkins School of Nursing, Baltimore, Maryland
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6
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Eno AK, Thomas AG, Ruck JM, Van Pilsum Rasmussen SE, Halpern SE, Waldram MM, Muzaale AD, Purnell TS, Massie AB, Garonzik Wang JM, Lentine KL, Segev DL, Henderson ML. Assessing the Attitudes and Perceptions Regarding the Use of Mobile Health Technologies for Living Kidney Donor Follow-Up: Survey Study. JMIR Mhealth Uhealth 2018; 6:e11192. [PMID: 30305260 PMCID: PMC6231841 DOI: 10.2196/11192] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 07/03/2018] [Accepted: 07/05/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND In 2013, the Organ Procurement and Transplantation Network began requiring transplant centers in the United States to collect and report postdonation living kidney donor follow-up data at 6 months, 1 year, and 2 years. Despite this requirement, <50% of transplant centers have been able to collect and report the required data. Previous work identified a number of barriers to living kidney donor follow-up, including logistical and administrative barriers for transplant centers and cost and functional barriers for donors. Novel smartphone-based mobile health (mHealth) technologies might reduce the burden of living kidney donor follow-up for centers and donors. However, the attitudes and perceptions toward the incorporation of mHealth into postdonation care among living kidney donors are unknown. Understanding donor attitudes and perceptions will be vital to the creation of a patient-oriented mHealth system to improve living donor follow-up in the United States. OBJECTIVE The goal of this study was to assess living kidney donor attitudes and perceptions associated with the use of mHealth for follow-up. METHODS We developed and administered a cross-sectional 14-question survey to 100 living kidney donors at our transplant center. All participants were part of an ongoing longitudinal study of long-term outcomes in living kidney donors. The survey included questions on smartphone use, current health maintenance behaviors, accessibility to health information, and attitudes toward using mHealth for living kidney donor follow-up. RESULTS Of the 100 participants surveyed, 94 owned a smartphone (35 Android, 58 iPhone, 1 Blackberry), 37 had accessed their electronic medical record on their smartphone, and 38 had tracked their exercise and physical activity on their smartphone. While 77% (72/93) of participants who owned a smartphone and had asked a medical question in the last year placed the most trust with their doctors, nurses, or other health care professionals regarding answering a health-related question, 52% (48/93) most often accessed health information elsewhere. Overall, 79% (74/94) of smartphone-owning participants perceived accessing living kidney donor information and resources on their smartphone as useful. Additionally, 80% (75/94) perceived completing some living kidney donor follow-up via mHealth as useful. There were no significant differences in median age (60 vs 59 years; P=.65), median years since donation (10 vs 12 years; P=.45), gender (36/75, 36%, vs 37/75, 37%, male; P=.57), or race (70/75, 93%, vs 18/19, 95%, white; P=.34) between those who perceived mHealth as useful for living kidney donor follow-up and those who did not, respectively. CONCLUSIONS Overall, smartphone ownership was high (94/100, 94.0%), and 79% (74/94) of surveyed smartphone-owning donors felt that it would be useful to complete their required follow-up with an mHealth tool, with no significant differences by age, sex, or race. These results suggest that patients would benefit from an mHealth tool to perform living donor follow-up.
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Affiliation(s)
- Ann K Eno
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Alvin G Thomas
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Department of Epidemiology, University of North Carolina, Chapel Hill, NC, United States
| | - Jessica M Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | | | - Samantha E Halpern
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Duke University School of Medicine, Durham, NC, United States
| | - Madeleine M Waldram
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Abimereki D Muzaale
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Tanjala S Purnell
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, United States.,Department of Health, Behavior, and Society, Johns Hopkins School of Public Health, Baltimore, MD, United States
| | - Allan B Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, United States
| | | | - Krista L Lentine
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, MO, United States
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, United States.,Department of Acute and Chronic Care, Johns Hopkins School of Nursing, Baltimore, MD, United States
| | - Macey L Henderson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Department of Acute and Chronic Care, Johns Hopkins School of Nursing, Baltimore, MD, United States
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7
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Lam NN, Lentine KL, Klarenbach S, Sood MM, Kuwornu PJ, Naylor KL, Knoll GA, Kim SJ, Young A, Garg AX. Validation of Living Donor Nephrectomy Codes. Can J Kidney Health Dis 2018; 5:2054358118760833. [PMID: 29662679 PMCID: PMC5896849 DOI: 10.1177/2054358118760833] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 11/15/2017] [Indexed: 11/21/2022] Open
Abstract
Background: Use of administrative data for outcomes assessment in living kidney donors is increasing given the rarity of complications and challenges with loss to follow-up. Objective: To assess the validity of living donor nephrectomy in health care administrative databases compared with the reference standard of manual chart review. Design: Retrospective cohort study. Setting: 5 major transplant centers in Ontario, Canada. Patients: Living kidney donors between 2003 and 2010. Measurements: Sensitivity and positive predictive value (PPV). Methods: Using administrative databases, we conducted a retrospective study to determine the validity of diagnostic and procedural codes for living donor nephrectomies. The reference standard was living donor nephrectomies identified through the province’s tissue and organ procurement agency, with verification by manual chart review. Operating characteristics (sensitivity and PPV) of various algorithms using diagnostic, procedural, and physician billing codes were calculated. Results: During the study period, there were a total of 1199 living donor nephrectomies. Overall, the best algorithm for identifying living kidney donors was the presence of 1 diagnostic code for kidney donor (ICD-10 Z52.4) and 1 procedural code for kidney procurement/excision (1PC58, 1PC89, 1PC91). Compared with the reference standard, this algorithm had a sensitivity of 97% and a PPV of 90%. The diagnostic and procedural codes performed better than the physician billing codes (sensitivity 60%, PPV 78%). Limitations: The donor chart review and validation study was performed in Ontario and may not be generalizable to other regions. Conclusions: An algorithm consisting of 1 diagnostic and 1 procedural code can be reliably used to conduct health services research that requires the accurate determination of living kidney donors at the population level.
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Affiliation(s)
- Ngan N Lam
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Canada
| | - Krista L Lentine
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, MO, USA
| | - Scott Klarenbach
- Department of Medicine, Division of Nephrology, University of Alberta, Edmonton, Canada
| | - Manish M Sood
- Department of Medicine, Division of Nephrology, Kidney Research Centre, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Health Research Institute, Ontario, Canada
| | - Paul J Kuwornu
- Institute for Clinical Evaluative Sciences, Ontario, Canada
| | - Kyla L Naylor
- Institute for Clinical Evaluative Sciences, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada
| | - Gregory A Knoll
- Department of Medicine, Division of Nephrology, Kidney Research Centre, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Health Research Institute, Ontario, Canada
| | - S Joseph Kim
- Institute for Clinical Evaluative Sciences, Ontario, Canada.,Department of Medicine, Division of Nephrology, University of Toronto, Ontario, Canada
| | - Ann Young
- Department of Medicine, Division of Nephrology, University of Toronto, Ontario, Canada
| | - Amit X Garg
- Institute for Clinical Evaluative Sciences, Ontario, Canada.,Department of Medicine, Division of Nephrology, Western University, London, Ontario, Canada.,Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
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8
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Expectations and Experiences of Follow-up and Self-Care After Living Kidney Donation: A Focus Group Study. Transplantation 2017; 101:2627-2635. [PMID: 28538499 DOI: 10.1097/tp.0000000000001771] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Ensuring donor wellbeing warrants ongoing monitoring after living kidney donation. However, there is considerable variability in donor follow-up processes, including information provided to donors regarding self-care. Loss to follow-up is common, suggesting that the aims and benefits of monitoring and follow-up may not be apparent. We aimed to describe the experiences and expectations of living kidney donors regarding follow-up and self-care after donation. METHODS Participants from 3 transplant centers in Australia and Canada participated in 14 focus groups (n = 123). Transcripts were analyzed thematically. RESULTS We identified 4 themes: lacking identification as a patient (invincibility and confidence in health, immediate return to normality, avoid burdening specialty services, redundancy of specialist attention, unnecessary travel), empowerment for health (self-preservation for devastating consequences, self-advocacy and education, needing lifestyle advice, tracking own results), safety net and reassurance (availability of psychosocial support, confidence in kidney-focused care, continuity and rapport, and access to waitlist priority), and neglect and inattention (unrecognized ongoing debilitations, primary focus on recipient, hospital abandonment, overlooking individual priorities, disconnected from system, coping with dual roles, and lacking support for financial consequences). CONCLUSIONS Living kidney donors who felt well and confident about their health regarded specialist follow-up as largely unnecessary. However, some felt they did not receive adequate medical attention, were prematurely detached from the health system, or held unresolved anxieties about the consequences of their decision to donate. Ongoing access to healthcare, psychosocial support, and education may reassure donors that any risks to their health are minimized.
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9
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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: 195] [Impact Index Per Article: 27.9] [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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10
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Torres X, Comas J, Arcos E, Tort J, Diekmann F. Death of recipients after kidney living donation triples donors' risk of dropping out from follow-up: a retrospective study. Transpl Int 2017; 30:603-610. [PMID: 28252226 DOI: 10.1111/tri.12946] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 08/25/2016] [Accepted: 02/24/2017] [Indexed: 11/28/2022]
Abstract
Although kidney transplantation from the donation of a living donor is a safe treatment for end-stage renal disease, inferences about safety of living kidney donors might be biased by an informative censoring caused by the noninclusion of a substantial percentage of donors lost to follow-up. With the aim of assessing the presence of a potential informative censoring in living kidney donation outcomes of Catalan donors for a period of 12 years, 573 donors followed and lost to follow-up were compared. Losses of follow-up over time were also assessed by univariate and multivariate survival analysis, along with Cox regression. Younger and older ages, and the death of their recipient differentiated those donors who were lost to follow-up over time. The risk of dropping out from follow-up was more than twofold for the youngest and oldest donors, and almost threefold for those donors whose recipient died. Results of studies on postdonation outcomes of Catalan living kidney donors might have overlooked older and younger cases, and, remarkably, a percentage of donors whose recipient died. If these donors showed a higher incidence of psychological problems, conclusions about living donors' safety might be compromised thus emphasizing the necessity of sustained surveillance of donors and prompt identification of these cases.
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Affiliation(s)
- Xavier Torres
- Psychiatry and Clinical Psychology Service, Institut Clínic de Neurociències, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Jordi Comas
- Catalan Renal Registry, Catalan Transplant Organization, Health Department, Generalitat of Catalonia, Barcelona, Spain
| | - Emma Arcos
- Catalan Renal Registry, Catalan Transplant Organization, Health Department, Generalitat of Catalonia, Barcelona, Spain
| | - Jaume Tort
- Catalan Renal Registry, Catalan Transplant Organization, Health Department, Generalitat of Catalonia, Barcelona, Spain
| | - Fritz Diekmann
- Department of Nephrology and Kidney Transplantation, Hospital Clínic de Barcelona, Barcelona, Spain
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11
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Abstract
Cigarette smoking affects many organs. It causes vasoconstriction through activation of sympathetic nervous system which leads to elevation of blood pressure and reduction in glomerular filtration rate and filtration pressure. It also causes thickening of renal arterioles. Cigarette smoking increases the risk of microalbuminuria and accelerates progression of microalbuminuria to macroalbuminuria. Furthermore, it causes rapid loss of glomerular filtration rate in chronic kidney disease patients. After kidney donation, these factors may be injurious to the solitary kidney. Kidney donors with history of cigarette smoking are prone to develop perioperative complications, pneumonia, and wound infection. Postkidney transplantation various stressors including warm and cold ischemia time, delayed graft function, and exposure to calcineurin inhibitors may result in poor graft function. Continuation of cigarette smoking in kidney transplant recipients will add further risk. In this review, we will specifically discuss the effects of cigarette smoking on normal kidneys, live kidney donors, and kidney transplant recipients. This will include adverse effects of cigarette smoking on graft and patient survival, cardiovascular events, rejection, infections, and cancers in kidney transplant recipients. Lastly, the impact of kidney transplantation on behavior and smoking cessation will also be discussed.
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12
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Kulkarni S, Thiessen C, Formica RN, Schilsky M, Mulligan D, D'Aquila R. The Long-Term Follow-up and Support for Living Organ Donors: A Center-Based Initiative Founded on Developing a Community of Living Donors. Am J Transplant 2016; 16:3385-3391. [PMID: 27500361 DOI: 10.1111/ajt.14005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 07/08/2016] [Accepted: 08/04/2016] [Indexed: 01/25/2023]
Abstract
Transplant professionals recognize that the long-term follow-up of living organ donors is a priority, yet there has been no implemented solution to this problem. This critical gap is essential, because the transplant field is now emphasizing living donation as a means to address the organ shortage. We detail our living donor initiative, which sets several priorities we recognize as fundamental to persons who have donated organs at our transplant center. This intervention attempts to mitigate the donor and center factors that are known to contribute to the lack of long-term follow-up. Beyond that, our goals are aimed at providing ongoing engagement, wellness, clinical data accrual, laboratory follow-up, and social support for our living donors, in continuity. Our ultimate goal is to nurture the development of local living donor community networks by providing social engagement for current and past donors, which also serves as a platform for greater population education on the societal importance of living donation. This initiative is based on joint recognition by our transplant team and our hospital leadership that supporting the long-term welfare of living donors is essential to accomplishing the goal of expanding living donor transplantation. The transplant team and hospital missions are aligned, and both contribute resources to the initiative.
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Affiliation(s)
- S Kulkarni
- The Center for Living Organ Donors, Yale-New Haven Hospital, New Haven, CT.,Department of Surgery, Yale University School of Medicine, New Haven, CT.,Department of Medicine, Yale University School of Medicine, New Haven, CT
| | - C Thiessen
- The Center for Living Organ Donors, Yale-New Haven Hospital, New Haven, CT.,Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - R N Formica
- The Center for Living Organ Donors, Yale-New Haven Hospital, New Haven, CT.,Department of Surgery, Yale University School of Medicine, New Haven, CT.,Department of Medicine, Yale University School of Medicine, New Haven, CT
| | - M Schilsky
- The Center for Living Organ Donors, Yale-New Haven Hospital, New Haven, CT.,Department of Surgery, Yale University School of Medicine, New Haven, CT.,Department of Medicine, Yale University School of Medicine, New Haven, CT
| | - D Mulligan
- The Center for Living Organ Donors, Yale-New Haven Hospital, New Haven, CT.,Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - R D'Aquila
- The Center for Living Organ Donors, Yale-New Haven Hospital, New Haven, CT.,Office of the President, Yale-New Haven Hospital, New Haven, CT
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13
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Patient-Reported Outcomes Following Living Kidney Donation: A Single Center Experience. J Clin Psychol Med Settings 2016; 22:160-8. [PMID: 26123551 DOI: 10.1007/s10880-015-9424-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
This article describes the development and implementation of an initiative at one transplant center to annually assess psychosocial outcomes of living kidney donors. The current analysis focuses on a cohort of adults (n = 208) who donated a kidney at BIDMC between September 2005 and August 2012, in which two post-donation annual assessments could be examined. One and two year post-donation surveys were returned by 59 % (n = 123) and 47 % (n = 98) of LKDs, respectively. Those who did not complete any survey were more likely to be younger (p = 0.001), minority race/ethnicity (p < 0.001), and uninsured at the time of donation (p = 0.01) compared to those who returned at least one of the two annual surveys. The majority of donors reported no adverse physical or psychosocial consequences of donation, high satisfaction with the donation experience, and no donation decision regret. However, a sizable minority of donors felt more pain intensity than expected and recovery time was much slower than expected, and experienced a clinically significant decline in vitality. We describe how these outcomes are used to inform clinical practice at our transplant center as well as highlight challenges in donor surveillance over time.
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14
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Abstract
In March 1966, the Ciba Foundation sponsored the first international, interdisciplinary symposium focused on ethical and legal issues in transplantation. The attendees included not only physicians and surgeons but also judges and legal scholars, a minister, and a science journalist. In this article, we will consider some of the topics in organ transplantation that were discussed by the attendees, what we have learned in the intervening half century, and the relevance of their discussions today. Specifically, we examine the definition of death and its implications for organ procurement, whether it is ethical and legal to "maim" a living individual for the benefit of another, how to ensure that the consent of the living donor is voluntary and informed, the case of identical twins, the question of whether ethically minors can serve as living donors, the health risks of living donation, the ethics and legality of an organ market, and the economic barriers to living donation. We show that many of the concerns discussed at the Ciba symposium remain highly relevant, and their discussions have helped to shape the ethical boundaries of organ transplantation today.
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15
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Grams ME, Sang Y, Levey AS, Matsushita K, Ballew S, Chang AR, Chow EK, Kasiske BL, Kovesdy CP, Nadkarni GN, Shalev V, Segev DL, Coresh J, Lentine KL, Garg AX. Kidney-Failure Risk Projection for the Living Kidney-Donor Candidate. N Engl J Med 2016; 374:411-21. [PMID: 26544982 PMCID: PMC4758367 DOI: 10.1056/nejmoa1510491] [Citation(s) in RCA: 299] [Impact Index Per Article: 37.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Evaluation of candidates to serve as living kidney donors relies on screening for individual risk factors for end-stage renal disease (ESRD). To support an empirical approach to donor selection, we developed a tool that simultaneously incorporates multiple health characteristics to estimate a person's probable long-term risk of ESRD if that person does not donate a kidney. METHODS We used risk associations from a meta-analysis of seven general population cohorts, calibrated to the population-level incidence of ESRD and mortality in the United States, to project the estimated long-term incidence of ESRD among persons who do not donate a kidney, according to 10 demographic and health characteristics. We then compared 15-year projections with the observed risk among 52,998 living kidney donors in the United States. RESULTS A total of 4,933,314 participants from seven cohorts were followed for a median of 4 to 16 years. For a 40-year-old person with health characteristics that were similar to those of age-matched kidney donors, the 15-year projections of the risk of ESRD in the absence of donation varied according to race and sex; the risk was 0.24% among black men, 0.15% among black women, 0.06% among white men, and 0.04% among white women. Risk projections were higher in the presence of a lower estimated glomerular filtration rate, higher albuminuria, hypertension, current or former smoking, diabetes, and obesity. In the model-based lifetime projections, the risk of ESRD was highest among persons in the youngest age group, particularly among young blacks. The 15-year observed risks after donation among kidney donors in the United States were 3.5 to 5.3 times as high as the projected risks in the absence of donation. CONCLUSIONS Multiple demographic and health characteristics may be used together to estimate the projected long-term risk of ESRD among living kidney-donor candidates and to inform acceptance criteria for kidney donors. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases and others.).
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Affiliation(s)
- Morgan E. Grams
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Yingying Sang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Andrew S. Levey
- Division of Nephrology at Tufts Medical Center, Boston, MA, USA
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Shoshana Ballew
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Alex R. Chang
- Division of Nephrology, Geisinger Medical Center, Danville, PA, USA
| | - Eric K.H. Chow
- Departments of Surgery and Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - Bertram L. Kasiske
- Department of Medicine, Hennepin County Medical Center, and University of Minnesota, Minneapolis, MN, USA
| | - Csaba P. Kovesdy
- Memphis Veterans Affairs Medical Center, Memphis, TN, USA
- University of Tennessee Health Science Center, Memphis, TN, USA
| | - Girish N. Nadkarni
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Varda Shalev
- Medical Division, Maccabi Healthcare Services and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dorry L. Segev
- Departments of Surgery and Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Krista L. Lentine
- Centers for Abdominal Transplantation and Outcomes Research, Saint Louis University, St. Louis, MO, USA
| | - Amit X. Garg
- Departments of Medicine and Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Ontario, Canada
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16
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Meyer K, Wahl AK, Bjørk IT, Wisløff T, Hartmann A, Andersen MH. Long-term, self-reported health outcomes in kidney donors. BMC Nephrol 2016; 17:8. [PMID: 26754798 PMCID: PMC4709885 DOI: 10.1186/s12882-016-0221-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 01/08/2016] [Indexed: 11/29/2022] Open
Abstract
Background The wide use of healthy persons as kidney donors calls for awareness of risks associated with donation. Live kidney donation may impair quality of life (QOL) and result in fatigue. Long-term data on these issues are generally lacking in the donor population. Thus we aimed to investigate long-term self-reported health outcomes in a nationwide donor cohort. Methods We assessed self-reported QOL, fatigue and psychosocial issues after donation in 217 donors representing 63 % of those who donated 8–12 years ago. QOL was measured using the generic Short Form-36 Health Survey (SF-36), fatigue using the Multidimensional Fatigue Inventory (MFI) and psychosocial issues using donor specific questions. For each of the 8 domains of SF-36 and the 5 domains of MFI, we performed generalized linear regression. Results Donors scored high on QOL with mean scores between 63.9 and 91.4 (scale 1–100) for the 8 subscales. Recognition from family and friends was associated with higher QOL scores in four domains. There were no significant gender differences. Fatigue scores were generally low. Females generally scored higher than males on all five dimensions of fatigue, although significantly only on two. Recipient still alive was associated with lower scores on mental fatigue. Regretting donors scored higher than average on all domains of fatigue. Recipient death, worries about own health and worsened relationship with the recipient influenced willingness to donate in retrospect. Donor age did not affect long-term health outcomes. Conclusions Eight till 12 years after donation QOL scores were generally high and improved with recogniton from family and friends. Fatigue was independent of donor age and more pronounced in females and in those who regretted donation.
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Affiliation(s)
- Käthe Meyer
- Department of Transplantation Medicine, Division of Cancer, Surgery and Transplantation, Oslo University Hospital, Rikshospitalet, Postbox 4950 Nydalen, 0424, Oslo, Norway. .,Department of Transplantation, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Astrid Klopstad Wahl
- Department of Health Sciences, Institute of Health and Society, University of Oslo, Oslo, Norway.
| | - Ida Torunn Bjørk
- Department of Nursing Science, Institute of Health and Society, University of Oslo, Oslo, Norway.
| | - Torbjørn Wisløff
- Oslo Centre for Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Oslo, Norway. .,Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, Oslo, Norway.
| | - Anders Hartmann
- Department of Transplantation Medicine, Division of Cancer, Surgery and Transplantation, Oslo University Hospital, Rikshospitalet, Postbox 4950 Nydalen, 0424, Oslo, Norway. .,Department of Transplantation, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Marit Helen Andersen
- Department of Transplantation Medicine, Division of Cancer, Surgery and Transplantation, Oslo University Hospital, Rikshospitalet, Postbox 4950 Nydalen, 0424, Oslo, Norway. .,Department of Health Sciences, Institute of Health and Society, University of Oslo, Oslo, Norway.
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17
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Mendelsohn AB, Dreyer NA, Mattox PW, Su Z, Swenson A, Li R, Turner JR, Velentgas P. Characterization of Missing Data in Clinical Registry Studies. Ther Innov Regul Sci 2015; 49:146-154. [PMID: 30222467 DOI: 10.1177/2168479014532259] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patterns of missing data are seldom well-characterized in observational research. This study examined the magnitude of, and factors associated with, missing data across multiple observational studies. Missingness was evaluated for demographic, clinical, and patient-reported outcome (PRO) data from a procedure registry (TOPS), a rare disease (cystic fibrosis) registry (Port-CF), and a comparative effectiveness registry (glaucoma, RiGOR). Generalized linear mixed effects models were fit to assess whether patient characteristics or follow-up methods predicted missingness. Data from 156,707 surgical procedures, 32,118 cystic fibrosis patients, and 2373 glaucoma patients were analyzed. Data were rarely missing for demographics, treatments, and outcomes. Missingness for clinical variables varied by registry and measure and depended on whether a variable was required. Within RiGOR, PRO forms were missing more often when collected by e-mail compared with office-based paper data collection. In Port-CF, missingness varied based on insurance status and sex. Strategic consideration of operational approaches affecting missing data should be performed prior to data collection and assessed periodically during study conduct.
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Affiliation(s)
| | - Nancy A Dreyer
- 1 Quintiles, Real-World & Late Phase Research, Cambridge, MA, USA
| | - Pattra W Mattox
- 1 Quintiles, Real-World & Late Phase Research, Cambridge, MA, USA
| | - Zhaohui Su
- 1 Quintiles, Real-World & Late Phase Research, Cambridge, MA, USA
| | - Anna Swenson
- 1 Quintiles, Real-World & Late Phase Research, Cambridge, MA, USA
| | - Rui Li
- 1 Quintiles, Real-World & Late Phase Research, Cambridge, MA, USA
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18
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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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19
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Seo CH, Ju JI, Kim MH, Jun KW, Ahn SH, Hwang JK, Kim SD, Park SC, Choi BS, Kim JI, Yang CW, Kim YS, Moon IS. Risk factors and long-term outcomes of delayed graft function in deceased donor renal transplantation. Ann Surg Treat Res 2015; 89:208-14. [PMID: 26446498 PMCID: PMC4595821 DOI: 10.4174/astr.2015.89.4.208] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 04/15/2015] [Accepted: 05/06/2015] [Indexed: 11/30/2022] Open
Abstract
Purpose The purpose of this study was to analyze the risk factors for delayed graft function (DGF) and determine its impact on the outcomes of deceased donor (DD) kidney transplantation (KT). Methods Between January 2000 and December 2011, we performed 195 DD renal transplants. After the exclusion of primary nonfunctional grafts (n = 4), the study recipients were divided into two groups-group I, DGF (n = 31, 16.2%); group II, non-DGF (n = 160, 83.8%). The following variables were compared: donor and recipient characteristics, patient and graft survival, postoperative renal function, acute rejection (AR) episodes, and the rates of surgical and infectious complications. Results Donor-related variables that showed significant differences included hypertension (P = 0.042), diabetes (P = 0.025), and prerecovery serum creatinine levels (P < 0.001). However, there were no significant differences in recipient-related factors. One significantly different transplant-related factor was positive panel reactive antibody (PRA > 20%, P = 0.008). On multivariate analysis, only the prerecovery serum creatinine level (P < 0.001; hazard ratio [HR], 1.814) was an independent risk factor for the development of DGF. A Cox multivariate analysis of risk factors for graft survival identified these independent risk factors for graft survival: nephron mass (donor kidney weight to recipient body weight ratio) index (P = 0.026; HR, 2.328), CMV infection (P = 0.038; HR, 0.114), and AR episode (P = 0.038; HR, 0.166). Conclusion In DD KT, an independent risk factor for DGF was the prerecovery serum creatinine level. Although there was a significant difference in graft survival between the DGF and non-DGF groups, DGF was not an independent risk factor for graft failure in this study.
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Affiliation(s)
- Chang Ho Seo
- Department of Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Jeong Il Ju
- Department of Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Mi-Hyeong Kim
- Department of Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Kang Woong Jun
- Department of Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Sang-Hyun Ahn
- Department of Surgery, Yeouido St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Jeong Kye Hwang
- Department of Surgery, Daejeon St. Mary's Hospital, The Catholic University of Korea College of Medicine, Daejeon, Korea
| | - Sang Dong Kim
- Department of Surgery, Incheon St. Mary's Hospital, The Catholic University of Korea College of Medicine, Incheon, Korea
| | - Sun Cheol Park
- Department of Surgery, Uijeongbu St. Mary's Hospital, The Catholic University of Korea College of Medicine, Uijeongbu, Korea
| | - Bum Soon Choi
- Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Ji Il Kim
- Department of Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Chul Woo Yang
- Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Yong Soo Kim
- Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - In Sung Moon
- Department of Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
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20
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Schold JD, Buccini LD, Rodrigue JR, Mandelbrot D, Goldfarb DA, Flechner SM, Kayler LK, Poggio ED. Critical Factors Associated With Missing Follow-Up Data for Living Kidney Donors in the United States. Am J Transplant 2015; 15:2394-403. [PMID: 25902877 DOI: 10.1111/ajt.13282] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 01/25/2015] [Accepted: 02/11/2015] [Indexed: 01/25/2023]
Abstract
Follow-up care for living kidney donors is an important responsibility of the transplant community. Prior reports indicate incomplete donor follow-up information, which may reflect both donor and transplant center factors. New UNOS regulations require reporting of donor follow-up information by centers for 2 years. We utilized national SRTR data to evaluate donor and center-level factors associated with completed follow-up for donors 2008-2012 (n = 30 026) using multivariable hierarchical logistic models. We compared center follow-up compliance based on current UNOS standards using adjusted and unadjusted models. Complete follow-up at 6, 12, and 24 months was 67%, 60%, and 50% for clinical and 51%, 40%, and 30% for laboratory data, respectively, but have improved over time. Donor risk factors for missing laboratory data included younger age 18-34 (adjusted odds ratio [AOR] = 2.03, 1.58-2.60), black race (AOR = 1.17, 1.05-1.30), lack of insurance (AOR = 1.25, 1.15-1.36), lower educational attainment (AOR = 1.19, 1.06-1.34), >500 miles to center (AOR = 1.78, 1.60-1.98), and centers performing >40 living donor transplants/year (AOR = 2.20, 1.21-3.98). Risk-adjustment moderately shifted classification of center compliance with UNOS standards. There is substantial missing donor follow-up with marked variation by donor characteristics and centers. Although follow-up has improved over time, targeted efforts are needed for donors with selected characteristics and at centers with higher living donor volume. Adding adjustment for donor factors to policies regulating follow-up may function to provide more balanced evaluation of center efforts.
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Affiliation(s)
- J D Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH.,Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH
| | - L D Buccini
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH.,Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - J R Rodrigue
- Beth Israel Deaconess Medical Center, Boston, MA
| | | | - D A Goldfarb
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - S M Flechner
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH.,Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | | | - E D Poggio
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH.,Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
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21
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Lam NN, Garg AX, Segev DL, Schnitzler MA, Xiao H, Axelrod D, Brennan DC, Kasiske BL, Tuttle-Newhall JE, Lentine KL. Gout after living kidney donation: correlations with demographic traits and renal complications. Am J Nephrol 2015; 41:231-40. [PMID: 25896309 DOI: 10.1159/000381291] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2015] [Accepted: 02/24/2015] [Indexed: 01/07/2023]
Abstract
BACKGROUND The demographic and clinical correlates of gout after living kidney donation are not well described. METHODS Using a unique database that integrates national registry identifiers of U.S. living kidney donors (1987-2007) with billing claims from a private health insurer (2000-2007), we identified post-donation gout based on medical diagnosis codes or pharmacy fills for gout therapies. The frequencies and demographic correlates of gout after donation were estimated by Cox regression with left- and right-censoring. We also compared the rates of renal diagnoses among donors with and without gout, matched in the ratio 1:3 by age, sex, and race. RESULTS The study sample of 4,650 donors included 13.1% African Americans. By seven years, African Americans were almost twice as likely to develop gout as Caucasian donors (4.4 vs. 2.4%; adjusted hazard ratio, aHR, 1.8; 95% confidence interval (CI) 1.0-3.2). Post-donation gout risk also increased with older age at donation (aHR per year 1.05) and was higher in men (aHR 2.80). Gout rates were similar in donors and age- and sex-matched general non-donors (rate ratio 0.86; 95% CI 0.66-1.13). Compared to matched donors without gout, donors with gout had more frequent renal diagnoses, reaching significance for acute kidney failure (rate ratio 12.5; 95% CI 1.5-107.0), chronic kidney disease (rate ratio 5.0; 95% CI 2.1-11.7), and other disorders of the kidney (rate ratio 2.2; 95% CI 1.2-4.2). CONCLUSION Donor subgroups at increased risk of gout include African Americans, older donors, and men. Donors with gout have a higher burden of renal complications after demographic adjustment.
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Affiliation(s)
- Ngan N Lam
- Division of Nephrology, Western University, London, Ont., Canada
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22
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Niemi M, Mandelbrot DA. The Outcomes of Living Kidney Donation from Medically Complex Donors: Implications for the Donor and the Recipient. CURRENT TRANSPLANTATION REPORTS 2014; 1:1-9. [PMID: 24579060 PMCID: PMC3933185 DOI: 10.1007/s40472-013-0001-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Living kidney donation is an important option for patients with end-stage renal disease (ESRD), and has improved life expectancy and quality for patients otherwise requiring maintenance dialysis or deceased-donor transplantation. Given the favorable outcomes of live donation and the shortage of organs to transplant, individuals with potentially unfavorable demographic and clinical characteristics are increasingly being permitted to donate kidneys. While this trend has successfully expanded the live donor pool, it has raised concerns as to which acceptance criteria are safe. This review aims to summarize the existing literature on the outcomes of transplantation from medically complex, living kidney donors, including both donor and recipient outcomes when available.
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Affiliation(s)
- Matthew Niemi
- Division of Nephrology, Department of Medicine Beth Israel Deaconess Medical Center 185 Pilgrim Road, Farr 8 Boston, MA 02215
| | - Didier A Mandelbrot
- The Transplant Center Beth Israel Deaconess Medical Center 110 Francis Street, LMOB 7 Boston, MA 02215
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23
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Lentine KL, Schnitzler MA, Garg AX, Xiao H, Axelrod D, Tuttle-Newhall JE, Brennan DC, Segev DL. Understanding antihypertensive medication use after living kidney donation through linked national registry and pharmacy claims data. Am J Nephrol 2014; 40:174-83. [PMID: 25196154 DOI: 10.1159/000365157] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2014] [Accepted: 06/07/2014] [Indexed: 01/11/2023]
Abstract
BACKGROUND Use of antihypertensive medications (AHM) after living kidney donation is not well described. METHODS We examined a database wherein national transplant registry data for 4,650 living kidney donors in 1987-2007 were linked to pharmacy claims from a US private health insurer (2000-2007 claims) to identify post-donation AHM fills. Cox regression with left- and right-censoring was used to estimate the frequencies and relative likelihood (adjusted hazards ratios, aHR) of post-donation AHM fills according to donor demographic traits. Medication possession ratio (MPRs), defined as (days of AHM dispensed)/(days observed), were also compared among donors and non-donor general beneficiaries. RESULTS Overall, 17.8% of the sample filled at least one AHM by 5 years post-donation. As compared with White living donors, African-Americans had 37% higher relative likelihood of any AHM use after donation (aHR 1.37, p < 0.0007), including significantly higher likelihoods of filling diuretics (aHR 2.25, p < 0.0001), ACEi/ARBs (aHR 1.46, p < 0.01), calcium channel blockers (aHR 1.56, p = 0.03), and vasodilators/other agents (aHR 2.17, p = 0.03). MPRs for any AHM and subcategories were lower among donors compared with age- and sex-matched non-donors. However, AHM MPRs rose in donors with multiple hypertension diagnoses, and prescription fill exposure for all AHM classes except diuretics was similar among donors and general non-donors with ≥ 3 hypertension diagnoses. CONCLUSIONS While AHM requirements are lower after kidney donation than among unscreened general persons, racial variation in AHM use occurs in privately insured donors. Demonstration of pharmaceutical care needs of insured donors supports the need for long-term follow-up and healthcare access for all donors.
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Affiliation(s)
- Krista L Lentine
- Center for Outcomes Research, Saint Louis University School of Medicine, St. Louis, Mo., USA
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Dew MA, Myaskovsky L, Steel JL, DiMartini AF. Managing the Psychosocial and Financial Consequences of Living Donation. CURRENT TRANSPLANTATION REPORTS 2013; 1:24-34. [PMID: 24592353 DOI: 10.1007/s40472-013-0003-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
There has been dramatic growth in the last decade in the literature on psychosocial and financial impacts of living organ donation. With this growth has come recognition that these impacts must be considered when educating prospective donors about the donation process, and when planning donor follow-up care after donation. Our review highlights recent studies that provide new information on the nature of psychosocial and financial outcomes in living donors, with special attention to studies examining unrelated donors (i.e., those with no biologic or longstanding emotional connection to the transplant patient), given that these individuals represent a growing segment of the living donor population. Limitations and gaps in available evidence are noted. We also discuss recent recommendations for post-donation monitoring of donors' psychosocial and financial outcomes, and we consider advances in evidence regarding interventions and prevention strategies to minimize any adverse psychosocial and financial impacts of living donation.
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Affiliation(s)
- Mary Amanda Dew
- Departments of Psychiatry, Psychology, Epidemiology, Biostatistics, and Clinical and Translational Science, University of Pittsburgh School of Medicine and Medical Center, 3811 O'Hara Street, Pittsburgh, PA 15213 USA, 412-624-3373
| | - Larissa Myaskovsky
- Departments of Medicine, Psychiatry and Clinical and Translational Science, University of Pittsburgh School of Medicine and Medical Center and Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, 230 McKee Place, Suite 600, Pittsburgh, PA 15213, 412-692-4856
| | - Jennifer L Steel
- Departments of Surgery, Psychiatry and Psychology, University of Pittsburgh School of Medicine and Medical Center, 3459 Fifth Avenue; MUH 7S, Pittsburgh PA 15213, 412-692-2041
| | - Andrea F DiMartini
- Departments of Psychiatry and Surgery, University of Pittsburgh School of Medicine and Medical Center, 3811 O'Hara Street, Pittsburgh, PA 15213 USA, 412-383-3166
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Abstract
BACKGROUND Although U.S. transplantation programs must submit living-donor follow-up data through 2 years after donation, the submissions have high rates of incomplete or missing data. It is important to understand barriers programs face in collecting follow-up information. METHODS Two hundred thirty-one programs performing living kidney donor (LKD) and/or living liver donor (LLD) transplantation were contacted to complete a survey about program attitudes concerning donor follow-up, follow-up practices, and barriers to success. RESULTS Respondents representing 147 programs (111 with only LKD and 36 with both LKD and LLD) participated. Sixty-eight percent of LKD and 83% of LLD respondents said that achieving follow-up was a high priority. The majority agreed that donors should be followed at least 2 years (61% LKD programs and 73% LLD programs), and sizeable percentages (31% LKD and 37% LLD) endorsed 5 years of follow-up. However, approximately 40% of programs lost contact with more than 75% of their donors by 2 years after donation. Follow-up barriers included donors not wanting to return to the program (87%), out-of-date contact information (73%), and lack of program (54%) or donor (49%) reimbursement for follow-up costs. Whereas 92% of LKD and 96% of LLD programs inform potential donors about follow-up requirements, fewer (67% LKD and 78% LLD) develop plans with donors to achieve follow-up. CONCLUSIONS Most respondents agree that donor follow-up is important, but they report difficulty achieving it. Improvements may occur if programs work with donors to develop plans to achieve follow-up, programmatic standards are set for completeness in follow-up data reporting, and sufficient staff resources are available to ensure ongoing post-donation contact.
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Ethical considerations in live donor transplantation: should complications be tolerated? Curr Opin Organ Transplant 2013; 18:235-40. [PMID: 23425790 DOI: 10.1097/mot.0b013e32835f3f2c] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Although living donor transplantation is considered an ethically acceptable undertaking for the purpose of saving another's life, its safety remains under investigation. RECENT FINDINGS Although living donors undertake considerable medical risks for no direct medical benefit, the question remains whether the risks are acceptable and should be tolerated by providers and patients or whether additional interventions and safeguards are needed to reduce and/or prevent complications. By reviewing complication risk statistics and synthesizing empirical research regarding risk-taking thresholds and attitudes, this paper examines the possibilities for determining an acceptable level of complication risk for living donors. This paper also delineates the ethical tensions surrounding protecting donors from unnecessary risk versus respecting donor autonomy to accept risks, and concludes by discussing the importance of donor follow-up and the value of donor registries. SUMMARY In the absence of information on long-term donor outcomes, transplant centers should take special precautions to protect prospective donors given increasing pressures to reduce the organ shortage and concerns that donors often disregard risks to themselves to save the lives of others.
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Reimbursement for living kidney donor follow-up care: how often does donor insurance pay? Transplantation 2013; 94:1049-51. [PMID: 23060280 DOI: 10.1097/tp.0b013e31826cc9a1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Currently, many transplantation centers do not follow former living kidney donors on a long-term basis. Several potential barriers have been identified to provide this follow-up of former living kidney donors, including concerns that donor insurance will not reimburse transplantation centers or primary care physicians for this care. Here, we report the rates at which different insurance companies reimbursed our transplantation center for follow-up visits of living donors. METHODS We collected data on all yearly follow-up visits of living donors billed from January 1, 2007, to December 31, 2010, representing 82 different donors. Concurrent visits of their recipients were available for 47 recipients and were used as a control group. RESULTS We find that most bills for follow-up visits of living kidney donors were paid by insurance companies, at a rate similar to the reimbursement for recipient follow-up care. CONCLUSIONS Our findings suggest that, for former donors with insurance, inadequate reimbursement should not be a barrier in providing follow-up care.
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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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Lentine KL, Patel A. Risks and outcomes of living donation. Adv Chronic Kidney Dis 2012; 19:220-8. [PMID: 22732041 DOI: 10.1053/j.ackd.2011.09.005] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Accepted: 09/16/2011] [Indexed: 12/31/2022]
Abstract
Living donors supply approximately 40% of renal allografts in the United States. Based on current data, perioperative mortality after donor nephrectomy is approximately 3 per 10,000 cases, and major and minor perioperative complications affect approximately 3% to 6% and 22% of donors, respectively. Donor nephrectomy does not appear to increase long-term mortality compared with controls, nor does it appear to increase ESRD risk among white donors. Within the donor population, the likelihood of postdonation chronic renal failure and medical comorbidities such as hypertension and diabetes appears to be relatively higher among some donor subgroups, such as African Americans and obese donors, but the impact of uninephrectomy on the lifetime risks of adverse events expected without nephrectomy in these subgroups has not yet been defined. As national follow-up of living donors in the United States is limited in scope, duration, and completeness, additional methods for quantifying risk among diverse living donors are needed. In addition to improved national collection of follow-up data, possible sources of information on donor outcomes may include focused studies with carefully defined control groups, and database integration projects that link national donor registration records to other data sources. Given the growth and evolving characteristics of the living donor population, as well as changes in surgical techniques, tracking of short- and long-term risks after living kidney donation is vital to support truly informed consent and to maintain public trust in living donation. The transplant community must persist in their efforts to accurately assess risk across demographically diverse living kidney donors.
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Matas AJ, Delmonico FL. Living donation: the global perspective. Adv Chronic Kidney Dis 2012; 19:269-75. [PMID: 22732048 DOI: 10.1053/j.ackd.2012.05.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Revised: 05/03/2012] [Accepted: 05/07/2012] [Indexed: 01/10/2023]
Abstract
Of 195 independent countries in the world, 83 have transplant programs. Some countries (areas) have emphasized living donation; others, decreased donation. As a consequence, rates of living donation vary widely between geographic areas and often between countries within the same geographic area. The major ethical issue in living donation is the risk to the donor. Internationally, numerous guidelines have been developed outlining acceptable donor evaluation and criteria for approval. An ongoing issue is that there remains considerable variation between countries (and programs within a country) in evaluation and in acceptance criteria. A major problem for most countries is the shortage of organs. As a consequence, illegal or quasi-legal unregulated markets have developed in some areas. These markets have not provided protection for either donor or recipient. The transplant community has taken a unified stand against these underground unregulated markets.
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Ross LF, Glannon W, Gottlieb LJ, Richard Thistlethwaite J. Different Standards Are Not Double Standards: All Elective Surgical Patients Are Not Alike. THE JOURNAL OF CLINICAL ETHICS 2012. [DOI: 10.1086/jce201223203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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