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Zafar MN, Rizvi SAH. Providing "Free" Access to Dialysis and Transplant to the Disfranchised. A Sustainable Model for Low and Low Middle Income Countries (LMICs). Transpl Int 2023; 36:11290. [PMID: 37497280 PMCID: PMC10367084 DOI: 10.3389/ti.2023.11290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 06/15/2023] [Indexed: 07/28/2023]
Abstract
Pakistan is a low-middle income country where incidence of End Stage Kidney Disease (ESKD) is 100-150 per million population (pmp). Paucity and high costs of renal replacement therapy (RRT) renders the majority disfranchised, since the dialysis rate is 15 pmp and the transplant rate is 4-5 pmp. In view of this, our center started an integrated dialysis and transplant program where all treatment is provided "Free of Cost" to all patients, with lifelong follow-up and medications. The model is based on the concept of community-government partnership funded by both partners. The annual contribution in 2021 was $37.4 million. >1,500 patients were dialyzed daily, and 6-8 received transplants weekly. Of the 6,553 transplants performed between 1985-2021, 988 (15%) were children. Overall, the 1 and 5-year graft survival rate was 97% and 88%. The donor clinic has 3,786 donors in regular yearly follow-up for up to 30-35 years where ESKD prevalence is 0.29%. Access to dialysis was increased by establishing six satellite centers reducing patient time and travel costs. Cost reductions by dialyzer reuse and generic drugs resulted in an annual saving of $5.8 m. This sustainable model has overcome the inherent socio-economic, logistic, cultural, and gender biases in RRT in LMICs. It has provided RRT with equity to the disfranchised in Pakistan and can be replicated in other LMICs with community-government support.
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Affiliation(s)
- Mirza Naqi Zafar
- Department of Pathology, Sindh Institute of Urology and Transplantation, Karachi, Pakistan
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2
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Nasim A, Dodani SK, Rehman M, Babar ZU, Badlani S, Mushtaq M, Aziz T. Risk Factors and Outcome of Gram-Negative Bloodstream Infection in Living-Donor Renal Transplant Recipients: A Case-Control Study From Pakistan. EXP CLIN TRANSPLANT 2023; 21:562-567. [PMID: 37584536 DOI: 10.6002/ect.2023.0087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2023]
Abstract
OBJECTIVES Gram-negative rods are the most common cause of bloodstream infection in renal transplant recipients. Acute rejection, urologic abnormalities, and ureteral stents are risk factors. Graft dysfunction is independently associated with gram-negative rod bloodstream infection. Our aim is to investigate the incidence, risk factors, and outcome among living donor renal transplant recipients from Pakistan. MATERIALS AND METHODS In this case-control study, we reviewed the medical records until June 2021 of renal transplant recipients seen from 2015 to 2019 for gram negative bacteremia. For every case, controls were matched by age, date of transplant, and sex. Demographics, risk factors, graft function, and mortality were compared. Clinical features, immunosuppression, source of blood stream infection, and microbiology were noted in cases. RESULTS Of 1677 renal transplant recipients, 44 developed gram negative bacteremia. The incidence was 5.9 per 1000 person-years. Median time since transplant was 5 months. The most common source was urinary tract infection. On univariate analysis, antithymocyte globulin, urinary tract infection, and recurrent urinary tract infections were associated with gram negative bacteremia. On multivariate analysis, urinary tract infection (adjusted odds ratio = 3.46; 95% CI, 1.27-9.37) and recurrent urinary tract infections (adjusted odds ratio = 4.03; 95% CI, 1.15-14.15) were significant risk factors. We found no difference in 30-day mortality and estimated glomerular filtration rate on last follow-up between cases and controls. Kaplan-Meier survival curves showed significant differences in graft survival in patients with gram negative bacteremia. Escherichia coli was the most common organism, with 75% ceftriaxone and 13% imipenem resistance. CONCLUSIONS The most significant risk factor for gram negative rod bloodstream infection was recurrent urinary tract infections. Timely treatment and prevention of recurrent urinary tract infections areimperative for prevention of gram negative bacteremia.
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Affiliation(s)
- Asma Nasim
- From the Department of Infectious Diseases, Karachi, Pakistan
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3
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Jamil S, Zafar MN, Siddiqui S, Ayub S, Rizvi AUH. Recurrent Urinary Tract Infections in Renal Transplant Recipients: Risk Factors and Outcomes in Low-resource Settings. SAUDI JOURNAL OF KIDNEY DISEASES AND TRANSPLANTATION 2022; 33:761-773. [PMID: 38018718 DOI: 10.4103/1319-2442.390256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023] Open
Abstract
Recurrent urinary tract infections (UTIs) after kidney transplantation are a common problem adversely affecting graft outcomes. This retrospective study aimed to report the frequency and risk factors of recurrent UTI and their impact on graft and patient outcomes in kidney transplant recipients at the Sindh Institute of Urology and Transplantation, Karachi, Pakistan, in January-December 2015. Five-year graft and patient survival rates were compared among different groups using Kaplan-Meier analysis. Of the 251 recipients, 67 developed one episode of UTI. Of these 67, 29 had 76 episodes of recurrent UTI. Out of the 76 episodes of recurrent UTI, Escherichia coli was the most common pathogen in 32 cases. Organisms causing recurrent UTI showed resistance to carbapenem in 19 cases versus 2 in the non-recurrent UTI group (P = 0.006). The estimated glomerular filtration rate at 1 year was 57.8 ± 16.23 mL/min/1.73 m2 in the recurrent UTI group vs. 61.9 ± 15.7 mL/min/1.73 m2 in the non-recurrent UTI group (P = 0.001). Graft survival in the recurrent UTI group at 5 years was significantly lower (76%) than in the non-recurrent UTI (95%) and no UTI groups (93%) (log-rank P = 0.006), with no significant effect on patient survival in these groups (P = 0.429). The presence of double-J stent (P = 0.036) and cytomegalovirus infections (P = 0.013) independently predicted recurrent UTI. Recurrent UTIs are common in low-resource settings and adversely affect graft outcomes. Appropriate prophylaxis and treatment are important to reduce recurrent UTI to improve graft outcomes.
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Affiliation(s)
- Sana Jamil
- Department of Microbiology, Sind Institute of Urology and Transplantation, Karachi, Pakistan
| | - Mirza Naqi Zafar
- Department of Pathology, Sind Institute of Urology and Transplantation, Karachi, Pakistan
| | - Sulleha Siddiqui
- Department of Microbiology, Sind Institute of Urology and Transplantation, Karachi, Pakistan
| | - Salma Ayub
- Department of Chemical Pathology, Sind Institute of Urology and Transplantation, Karachi, Pakistan
| | - Adeeb-Ul-Hassan Rizvi
- Department of Urology, Sind Institute of Urology and Transplantation, Karachi, Pakistan
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Talbot B, Athavale A, Jha V, Gallagher M. Data Challenges in Addressing Chronic Kidney Disease in Low- and Lower-Middle-Income Countries. Kidney Int Rep 2021; 6:1503-1512. [PMID: 34169191 PMCID: PMC8207309 DOI: 10.1016/j.ekir.2021.03.901] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/17/2021] [Accepted: 03/29/2021] [Indexed: 12/17/2022] Open
Abstract
The burden of chronic kidney disease (CKD) is growing globally, particularly in low- and lower-middle-income countries (LLMICs) where access to treatment is poor and the largest increases in disease burden will occur. The individual and societal costs of kidney disease are well recognized, especially in developed health care systems where treatments for the advanced stages of CKD are more readily available. The consequences of CKD are potentially more catastrophic in developing health care systems where such resources are often lacking. Central to addressing this challenge is the availability of data to understand disease burden and ensure that investments in treatments and health resources are effective at a local level. Use of routinely collected administrative data is helpful in this regard, however, the barriers to developing a more systematic focus on data collection should not be underestimated. This article reviews the current tools that have been used to measure the burden of CKD and considers limitations regarding their use in LLMICs. A review of the literature investigating the use of registries, disease specific databases and administrative data to identify populations with CKD in LLMICs, which indicate these to be underused resources, is included. Suggestions regarding the potential use of administrative data for measuring CKD burden in LLMICs are explored.
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Affiliation(s)
- Benjamin Talbot
- The George Institute for Global Health, University of New South Wales, Sydney, Australia.,Concord Clinical School, University of Sydney, New South Wales, Australia
| | - Akshay Athavale
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Vivekanand Jha
- The George Institute for Global Health, University of New South Wales, New Delhi, India.,Manipal Academy of Higher Education (MAHE), Manipal, India.,School of Public Health, Imperial College, London, UK
| | - Martin Gallagher
- The George Institute for Global Health, University of New South Wales, Sydney, Australia.,Concord Clinical School, University of Sydney, New South Wales, Australia
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O'Connell PJ, Brown M, Chan TM, Claure-Del Granado R, Davies SJ, Eiam-Ong S, Hassan MH, Kalantar-Zadeh K, Levin A, Martin DE, Muller E, Ossareh S, Tchokhonelidze I, Trask M, Twahir A, Were AJO, Yang CW, Zemchenkov A, Harden PN. The role of kidney transplantation as a component of integrated care for chronic kidney disease. Kidney Int Suppl (2011) 2020; 10:e78-e85. [PMID: 32149012 DOI: 10.1016/j.kisu.2019.11.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 10/11/2019] [Accepted: 11/07/2019] [Indexed: 10/25/2022] Open
Abstract
Kidney transplant provides superior outcomes to dialysis as a treatment for end-stage kidney disease. Therefore, it is essential that kidney transplantation be part of an integrated treatment and management plan for chronic kidney disease (CKD). Developing an effective national program of transplantation is challenging because of the requirement for kidney donors and the need for a multidisciplinary team to provide expert care for both donors and recipients. This article outlines the steps necessary to establish a national kidney transplant program, starting with the requirement for effective legislation that provides the legal framework for transplantation whilst protecting organ donors, their families, recipients, and staff and is an essential requirement to combat organ trafficking. The next steps involve capacity building with the development of a multiskilled workforce, the credentialing of transplant centers, and the reporting of outcomes through national or regional registries. Although it is accepted that most transplant programs will begin with living related kidney donation, it is essential to aspire to and develop a deceased donor program. This requires engagement with multiple stakeholders, especially the patients, the general community, intensivists, and health departments. Development of transplant centers should be undertaken in concert with the development of a dialysis program. Both are essential components of integrated care for CKD and both should be viewed as part of the World Health Organization's initiative for universal health coverage. Provisions to cover the costs of treatment for patients need to be developed taking into account the state of development of the overall health framework in each country.
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Affiliation(s)
- Philip J O'Connell
- Renal Unit, University of Sydney at Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, The Westmead Institute for Medical Research, Westmead, New South Wales, Australia
| | - Mark Brown
- Department of Renal Medicine, St. George Hospital, Sydney, New South Wales, Australia
| | - Tak Mao Chan
- Division of Nephrology, Department of Medicine, University of Hong Kong, Hong Kong
| | - Rolando Claure-Del Granado
- Division of Nephrology, Department of Medicine, Hospital Obrero #2 -Caja Nacional de Salud, Universidad Mayor de San Simon School of Medicine, Cochabamba, Bolivia
| | - Simon J Davies
- Faculty of Medicine and Health Sciences, Keele University, Keele, UK
| | - Somchai Eiam-Ong
- Department of Medicine, Chulalongkorn Hospital, Bangkok, Thailand
| | - Mohamed H Hassan
- Division of Nephrology, Department of Medicine, Sheikh Khalifa Medical City, Abu Dhabi, UAE
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension, University of California Irvine Medical Center, Orange, California, USA
| | - Adeera Levin
- Division of Nephrology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Elmi Muller
- Transplant Unit, Department of Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Shahrzad Ossareh
- Division of Nephrology, Department of Medicine, Hasheminejad Kidney Center, Iran University of Medical Sciences, Tehran, Iran
| | - Irma Tchokhonelidze
- Nephrology Development Clinical Center, Tbilisi State Medical University, Tbilisi, Georgia
| | - Michele Trask
- School of Nursing, University of British Columbia, Vancouver, British Columbia, Canada.,Provincial Health Services Authority, Vancouver, British Columbia, Canada
| | - Ahmed Twahir
- Parklands Kidney Centre, Nairobi, Kenya.,Department of Medicine, The Aga Khan University Hospital, Nairobi, Kenya
| | - Anthony J O Were
- Renal Unit, Kenyatta National Hospital, Nairobi, Kenya.,School of Medicine, Clinical Medicine and Therapeutics, University of Nairobi, Nairobi, Kenya.,East African Kidney Institute, College of Health Sciences, University of Nairobi, Nairobi, Kenya
| | - Chih-Wei Yang
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Alexander Zemchenkov
- Department of Internal Disease and Nephrology, North-Western State Medical University named after I.I. Mechnikov, Saint Petersburg, Russia.,Department of Nephrology and Dialysis, Pavlov First Saint Petersburg State Medical University, Saint Petersburg, Russia
| | - Paul N Harden
- Oxford Kidney Unit, Oxford University Hospitals National Health Service Foundation Trust, Oxford, UK
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Matsukuma Y, Masutani K, Tanaka S, Tsuchimoto A, Nakano T, Okabe Y, Kakuta Y, Okumi M, Tsuruya K, Nakamura M, Kitazono T, Tanabe K. Development and validation of a new prediction model for graft function using preoperative marginal factors in living-donor kidney transplantation. Clin Exp Nephrol 2019; 23:1331-1340. [PMID: 31444656 DOI: 10.1007/s10157-019-01774-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 08/06/2019] [Indexed: 01/17/2023]
Abstract
BACKGROUND Recently, living-donor kidney transplantation from marginal donors has been increasing. However, a simple prediction model for graft function including preoperative marginal factors is limited. Here, we developed and validated a new prediction model for graft function using preoperative marginal factors in living-donor kidney transplantation. METHODS We retrospectively investigated 343 patients who underwent living-donor kidney transplantation at Kyushu University Hospital (derivation cohort). Low graft function was defined as an estimated glomerular filtration rate of < 45 mL/min/1.73 m2 at 1 year. A prediction model was developed using a multivariable logistic regression model, and verified using data from 232 patients who underwent living-donor kidney transplantation at Tokyo Women's Medical University Hospital (validation cohort). RESULTS In the derivation cohort, 89 patients (25.9%) had low graft function at 1 year. Donor age, donor-estimated glomerular filtration rate, donor hypertension, and donor/recipient body weight ratio were selected as predictive factors. This model demonstrated modest discrimination (c-statistic = 0.77) and calibration (Hosmer-Lemeshow test, P = 0.83). Furthermore, this model demonstrated good discrimination (c-statistic = 0.76) and calibration (Hosmer-Lemeshow test, P = 0.54) in the validation cohort. Furthermore, donor age, donor-estimated glomerular filtration rate, and donor hypertension were strongly associated with glomerulosclerosis and atherosclerotic vascular changes in the "zero-time" biopsy. CONCLUSIONS This model using four pre-operative variables will be a simple, but useful guide to estimate graft function at 1 year after kidney transplantation, especially in marginal donors, in the clinical setting.
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Affiliation(s)
- Yuta Matsukuma
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Kosuke Masutani
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan. .,Division of Nephrology and Rheumatology, Department of Internal Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan.
| | - Shigeru Tanaka
- Division of Internal Medicine, Fukuoka Dental College, Fukuoka, Japan
| | - Akihiro Tsuchimoto
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Toshiaki Nakano
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yasuhiro Okabe
- Department of Surgery and Oncology, Kyushu University, Fukuoka, Japan
| | - Yoichi Kakuta
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | - Masayoshi Okumi
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
| | | | - Masafumi Nakamura
- Department of Surgery and Oncology, Kyushu University, Fukuoka, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Kazunari Tanabe
- Department of Urology, Tokyo Women's Medical University, Tokyo, Japan
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7
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Hernández D, Alonso-Titos J, Armas-Padrón AM, Ruiz-Esteban P, Cabello M, López V, Fuentes L, Jironda C, Ros S, Jiménez T, Gutiérrez E, Sola E, Frutos MA, González-Molina M, Torres A. Mortality in Elderly Waiting-List Patients Versus Age-Matched Kidney Transplant Recipients: Where is the Risk? Kidney Blood Press Res 2018; 43:256-275. [PMID: 29490298 DOI: 10.1159/000487684] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 02/15/2018] [Indexed: 11/19/2022] Open
Abstract
The number of elderly patients on the waiting list (WL) for kidney transplantation (KT) has risen significantly in recent years. Because KT offers a better survival than dialysis therapy, even in the elderly, candidates for KT should be selected carefully, particularly in older waitlisted patients. Identification of risk factors for death in WL patients and prediction of both perioperative risk and long-term post-transplant mortality are crucial for the proper allocation of organs and the clinical management of these patients in order to decrease mortality, both while on the WL and after KT. In this review, we examine the clinical results in studies concerning: a) risk factors for mortality in WL patients and KT recipients; 2) the benefits and risks of performing KT in the elderly, comparing survival between patients on the WL and KT recipients; and 3) clinical tools that should be used to assess the perioperative risk of mortality and predict long-term post-transplant survival. The acknowledgment of these concerns could contribute to better management of high-risk patients and prophylactic interventions to prolong survival in this particular population, provided a higher mortality is assumed.
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Affiliation(s)
- Domingo Hernández
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, Málaga, Spain
| | - Juana Alonso-Titos
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, Málaga, Spain
| | | | - Pedro Ruiz-Esteban
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, Málaga, Spain
| | - Mercedes Cabello
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, Málaga, Spain
| | - Verónica López
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, Málaga, Spain
| | - Laura Fuentes
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, Málaga, Spain
| | - Cristina Jironda
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, Málaga, Spain
| | - Silvia Ros
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, Málaga, Spain
| | - Tamara Jiménez
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, Málaga, Spain
| | - Elena Gutiérrez
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, Málaga, Spain
| | - Eugenia Sola
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, Málaga, Spain
| | - Miguel Angel Frutos
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, Málaga, Spain
| | - Miguel González-Molina
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, Málaga, Spain
| | - Armando Torres
- Nephrology Department, Hospital Universitario de Canarias, CIBICAN, University of La Laguna, Tenerife and Instituto Reina Sofía de Investigación Renal, IRSIN, Tenerife, Spain
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