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Patel K, Brotherton A, Chaudhry D, Evison F, Nieto T, Dabare D, Sharif A. Survival Advantage Comparing Older Living Donor Versus Standard Criteria Donor Kidney Transplants. Transpl Int 2024; 37:12559. [PMID: 38529216 PMCID: PMC10961822 DOI: 10.3389/ti.2024.12559] [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: 12/13/2023] [Accepted: 02/14/2024] [Indexed: 03/27/2024]
Abstract
The aim of this analysis was to explore mortality outcomes for kidney transplant candidates receiving older living donor kidneys (age ≥60 years) versus younger deceased donors or remaining on dialysis. From 2000 to 2019, all patients on dialysis listed for their first kidney-alone transplant were included in a retrospective cohort analysis of UK transplant registry data. The primary outcome was all-cause mortality, with survival analysis conducted by intention-to-treat principle. Time-to-death from listing was modelled using nonproportional hazard Cox regression models with transplantation handled as a time-dependent covariate. A total of 32,978 waitlisted kidney failure patients formed the primary study cohort, of whom 18,796 (58.5%) received a kidney transplant (1,557 older living donor kidneys and 18,062 standard criteria donor kidneys). Older living donor kidney transplantation constituted only 17.0% of all living donor kidney transplant activity (overall cohort; n = 9,140). Recipients of older living donor kidneys had reduced all-cause mortality compared to receiving SCD kidneys (HR 0.904, 95% CI 0.845-0.967, p = 0.003) and much lower all-cause mortality versus remaining on the waiting list (HR 0.160, 95% CI 0.149-0.172, p < 0.001). Older living kidney donors should be actively explored to expand the living donor kidney pool and are an excellent treatment option for waitlisted kidney transplant candidates.
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Affiliation(s)
- Kamlesh Patel
- Department of Nephrology and Transplantation, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Anna Brotherton
- Department of Nephrology and Transplantation, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Daoud Chaudhry
- School of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Felicity Evison
- Data Science Team, Research Development and Innovation, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Thomas Nieto
- Department of Nephrology and Transplantation, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Dilan Dabare
- Department of Nephrology and Transplantation, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Adnan Sharif
- Department of Nephrology and Transplantation, University Hospitals Birmingham, Birmingham, United Kingdom
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
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2
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Patel K, Brotherton A, Chaudhry D, Evison F, Nieto T, Dabare D, Sharif A. All Expanded Criteria Donor Kidneys are Equal But are Some More Equal Than Others? A Population-Cohort Analysis of UK Transplant Registry Data. Transpl Int 2023; 36:11421. [PMID: 37727380 PMCID: PMC10505656 DOI: 10.3389/ti.2023.11421] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 07/31/2023] [Indexed: 09/21/2023]
Abstract
Survival outcomes for kidney transplant candidates based on expanded criteria donor (ECD) kidney type is unknown. A retrospective cohort study was undertaken of prospectively collected registry data of all waitlisted kidney failure patients receiving dialysis in the United Kingdom. All patients listed for their first kidney-alone transplant between 2000-2019 were included. Treatment types included; living donor; standard criteria donor (SCD); ECD60 (deceased donor aged ≥60 years); ECD50-59 (deceased donor aged 50-59 years with two from the following three; hypertension; raised creatinine and/or death from stroke) or remains on dialysis. The primary outcome was all-cause mortality, with time-to-death from listing analyzed using time-dependent non-proportional Cox regression models. The study cohort comprised 47,917 waitlisted kidney failure patients, of whom 34,558 (72.1%) received kidney transplantation. ECD kidneys (n = 7,356) were stratified as ECD60 (n = 7,009) or ECD50-59 (n = 347). Compared to SCD, both ECD60 (Hazard Ratio 1.126, 95% CI 1.093-1.161) and ECD50-59 (Hazard Ratio 1.228, 95% CI 1.113-1.356) kidney recipients have higher all-cause mortality. However, compared to dialysis, both ECD60 (Hazard Ratio 0.194, 95% CI 0.187-0.201) and ECD50-59 (Hazard Ratio 0.218, 95% CI 0.197-0.241) kidney recipients have lower all-cause mortality. ECD kidneys, regardless of definition, provide equivalent and superior survival benefits in comparison to remaining waitlisted.
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Affiliation(s)
- Kamlesh Patel
- Department of Nephrology and Transplantation, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Anna Brotherton
- Department of Nephrology and Transplantation, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Daoud Chaudhry
- School of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Felicity Evison
- Data Science Team, Research Development and Innovation, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Thomas Nieto
- Department of Nephrology and Transplantation, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Dilan Dabare
- Department of Nephrology and Transplantation, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Adnan Sharif
- Department of Nephrology and Transplantation, University Hospitals Birmingham, Birmingham, United Kingdom
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
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3
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Nimmo A, Latimer N, Oniscu GC, Ravanan R, Taylor DM, Fotheringham J. Propensity Score and Instrumental Variable Techniques in Observational Transplantation Studies: An Overview and Worked Example Relating to Pre-Transplant Cardiac Screening. Transpl Int 2022; 35:10105. [PMID: 35832035 PMCID: PMC9271574 DOI: 10.3389/ti.2022.10105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 05/25/2022] [Indexed: 11/24/2022]
Abstract
Inferring causality from observational studies is difficult due to inherent differences in patient characteristics between treated and untreated groups. The randomised controlled trial is the gold standard study design as the random allocation of individuals to treatment and control arms should result in an equal distribution of known and unknown prognostic factors at baseline. However, it is not always ethically or practically possible to perform such a study in the field of transplantation. Propensity score and instrumental variable techniques have theoretical advantages over conventional multivariable regression methods and are increasingly being used within observational studies to reduce the risk of confounding bias. An understanding of these techniques is required to critically appraise the literature. We provide an overview of propensity score and instrumental variable techniques for transplant clinicians, describing their principles, assumptions, strengths, and weaknesses. We discuss the different patient populations included in analyses and how to interpret results. We illustrate these points using data from the Access to Transplant and Transplant Outcome Measures study examining the association between pre-transplant cardiac screening in kidney transplant recipients and post-transplant cardiac events.
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Affiliation(s)
- Ailish Nimmo
- Renal Department, Southmead Hospital, North Bristol National Health Service Trust, Bristol, United Kingdom
- *Correspondence: Ailish Nimmo,
| | - Nicholas Latimer
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Gabriel C. Oniscu
- Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Rommel Ravanan
- Renal Department, Southmead Hospital, North Bristol National Health Service Trust, Bristol, United Kingdom
| | - Dominic M. Taylor
- Renal Department, Southmead Hospital, North Bristol National Health Service Trust, Bristol, United Kingdom
| | - James Fotheringham
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
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Redeker S, Ismail S, Eeren HV, Massey EK, Weimar W, Oppe M, Busschbach J. A dynamic Markov model to assess the cost-effectiveness of the Kidney Team at Home intervention in The Netherlands. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2022; 23:597-606. [PMID: 34647158 PMCID: PMC8513543 DOI: 10.1007/s10198-021-01383-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 09/28/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES The Kidney Team at Home program is an educational intervention aimed at patients with chronic kidney disease to assist them in their choice for kidney replacement therapy. Previous studies have shown that the intervention results in an increase in knowledge and communication on kidney replacement therapy, and eventually in an increase in the number of living donor kidney transplantations. The study assesses the cost-effectiveness of the intervention compared to standard care. METHODS A dynamic probabilistic Markov model was used to estimate the monetary and health benefits of the intervention in The Netherlands over 10 years. Data on costs and health-related quality of life were derived from the literature. Transition probabilities, prevalence, and incidence rates were calculated using a large national database. An optimistic and a pessimistic implementation scenario were compared to a base case scenario with standard care. RESULTS In both the optimistic and pessimistic scenario, the intervention is cost-effective and dominant compared to standard care: savings were €108,681,985 and €51,770,060 and the benefits were 1382 and 695 QALYs, respectively. CONCLUSIONS The superior cost-effectiveness of the intervention is caused by the superior health effects and the reduction of costs associated with transplantation, and the relatively small incremental costs of the intervention. The favorable findings of this implementation project resulted in national uptake of the intervention in The Netherlands as of 2021. This is the first time a psychosocial intervention has been implemented as part of standard care in a kidney replacement therapy program worldwide.
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Affiliation(s)
- Steef Redeker
- Erasmus Medical Center, Section of Medical Psychology and Psychotherapy, Department of Psychiatry, Postal Address, PO Box 2040, 3000 CA, Rotterdam, The Netherlands.
| | - Sohal Ismail
- Erasmus Medical Center, Section of Medical Psychology and Psychotherapy, Department of Psychiatry, Postal Address, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Hester V Eeren
- Erasmus Medical Center, Section of Medical Psychology and Psychotherapy, Department of Psychiatry, Postal Address, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Emma K Massey
- Erasmus MC, Transplant Institute, Department of Internal Medicine, Rotterdam, The Netherlands
| | - Willem Weimar
- Erasmus MC, Transplant Institute, Department of Internal Medicine, Rotterdam, The Netherlands
| | - Mark Oppe
- Maths in Health, Rotterdam, The Netherlands
| | - Jan Busschbach
- Erasmus Medical Center, Section of Medical Psychology and Psychotherapy, Department of Psychiatry, Postal Address, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
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Vaughan RH, Kresse J, Farmer LK, Thézénas ML, Kessler BM, Lindeman JHN, Sharples EJ, Welsh GI, Nørregaard R, Ploeg RJ, Kaisar M. Cytoskeletal protein degradation in brain death donor kidneys associates with adverse posttransplant outcomes. Am J Transplant 2022; 22:1073-1087. [PMID: 34878723 PMCID: PMC9305475 DOI: 10.1111/ajt.16912] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 11/16/2021] [Accepted: 11/17/2021] [Indexed: 01/25/2023]
Abstract
In brain death, cerebral injury contributes to systemic biological dysregulation, causing significant cellular stress in donor kidneys adversely impacting the quality of grafts. Here, we hypothesized that donation after brain death (DBD) kidneys undergo proteolytic processes that may deem grafts susceptible to posttransplant dysfunction. Using mass spectrometry and immunoblotting, we mapped degradation profiles of cytoskeletal proteins in deceased and living donor kidney biopsies. We found that key cytoskeletal proteins in DBD kidneys were proteolytically cleaved, generating peptide fragments, predominantly in grafts with suboptimal posttransplant function. Interestingly, α-actinin-4 and talin-1 proteolytic fragments were detected in brain death but not in circulatory death or living donor kidneys with similar donor characteristics. As talin-1 is a specific proteolytic target of calpain-1, we investigated a potential trigger of calpain activation and talin-1 degradation using human ex vivo precision-cut kidney slices and in vitro podocytes. Notably, we showed that activation of calpain-1 by transforming growth factor-β generated proteolytic fragments of talin-1 that matched the degradation fragments detected in DBD preimplantation kidneys, also causing dysregulation of the actin cytoskeleton in human podocytes; events that were reversed by calpain-1 inhibition. Our data provide initial evidence that brain death donor kidneys are more susceptible to cytoskeletal protein degradation. Correlation to posttransplant outcomes may be established by future studies.
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Affiliation(s)
- Rebecca H. Vaughan
- Research and DevelopmentNHS Blood and TransplantBristol & OxfordUK,Nuffield Department of Surgical SciencesOxford University Hospital OxfordBiomedical Research CentreUniversity of OxfordOxfordUK
| | | | - Louise K. Farmer
- Bristol RenalBristol Medical SchoolUniversity of BristolBristolUK
| | - Marie L. Thézénas
- Nuffield Department of MedicineTarget Discovery InstituteUniversity of OxfordOxfordUK
| | - Benedikt M. Kessler
- Nuffield Department of MedicineTarget Discovery InstituteUniversity of OxfordOxfordUK
| | - Jan H. N. Lindeman
- Department of SurgeryLeiden University Medical CentreLeidenThe Netherlands
| | | | - Gavin I. Welsh
- Bristol RenalBristol Medical SchoolUniversity of BristolBristolUK
| | | | - Rutger J. Ploeg
- Research and DevelopmentNHS Blood and TransplantBristol & OxfordUK,Nuffield Department of Surgical SciencesOxford University Hospital OxfordBiomedical Research CentreUniversity of OxfordOxfordUK,Department of SurgeryLeiden University Medical CentreLeidenThe Netherlands
| | - Maria Kaisar
- Research and DevelopmentNHS Blood and TransplantBristol & OxfordUK,Nuffield Department of Surgical SciencesOxford University Hospital OxfordBiomedical Research CentreUniversity of OxfordOxfordUK
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6
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van Dellen D, Burnapp L, Citterio F, Mamode N, Moorlock G, van Assche K, Zuidema WC, Lennerling A, Dor FJMF. Pre-emptive live donor kidney transplantation-moving barriers to opportunities: An ethical, legal and psychological aspects of organ transplantation view. World J Transplant 2021; 11:88-98. [PMID: 33954087 PMCID: PMC8058646 DOI: 10.5500/wjt.v11.i4.88] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 01/30/2021] [Accepted: 03/12/2021] [Indexed: 02/06/2023] Open
Abstract
Live donor kidney transplantation (LDKT) is the optimal treatment modality for end stage renal disease (ESRD), enhancing patient and graft survival. Pre-emptive LDKT, prior to requirement for renal replacement therapy (RRT), provides further advantages, due to uraemia and dialysis avoidance. There are a number of potential barriers and opportunities to promoting pre-emptive LDKT. Significant infrastructure is needed to deliver robust programmes, which varies based on socio-economic standards. National frameworks can impact on national prioritisation of pre-emptive LDKT and supporting education programmes. Focus on other programme’s components, including deceased kidney transplantation and RRT, can also hamper uptake. LDKT programmes are designed to provide maximal benefit to the recipient, which is specifically true for pre-emptive transplantation. Health care providers need to be educated to maximize early LDKT referral. Equitable access for varying population groups, without socio-economic bias, also requires prioritisation. Cultural barriers, including religious influence, also need consideration in developing successful outcomes. In addition, the benefit of pre-emptive LDKT needs to be emphasised, and opportunities provided to potential donors, to ensure timely and safe work-up processes. Recipient education and preparation for pre-emptive LDKT needs to ensure increased uptake. Awareness of the benefits of pre-emptive transplantation require prioritisation for this population group. We recommend an approach where patients approaching ESRD are referred early to pre-transplant clinics facilitating early discussion regarding pre-emptive LDKT and potential donors for LDKT are prioritized for work-up to ensure success. Education regarding pre-emptive LDKT should be the norm for patients approaching ESRD, appropriate for the patient’s cultural needs and physical status. Pre-emptive transplantation maximize benefit to potential recipients, with the potential to occur within successful service delivery. To fully embrace preemptive transplantation as the norm, investment in infrastructure, increased awareness, and donor and recipient support is required.
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Affiliation(s)
- David van Dellen
- Department of Renal and Pancreas Transplantation, Manchester University NHS Foundation Trust, Manchester M13 9WL, United Kingdom
- Department of Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, United Kingdom
| | - Lisa Burnapp
- Department of Transplantation, Guy's and St. Thomas' NHS Foundation Trust, London SE1 9RT, United Kingdom
| | - Franco Citterio
- Department of Surgery, Renal Transplantation, Catholic University, Rome 00153, Italy
| | - Nizam Mamode
- Department of Transplantation, Guy's and St. Thomas' NHS Foundation Trust, London SE1 9RT, United Kingdom
| | - Greg Moorlock
- Warwick Medical School, University of Warwick, Coventry CV4 7AL, United Kingdom
| | - Kristof van Assche
- Res Grp Personal Rights & Property Rights, University of Antwerp, Antwerp 2000, Belgium
| | - Willij C Zuidema
- Departments of Internal Medicine, Erasmus Medical Centre, Rotterdam CE 1015, Netherlands
| | - Annette Lennerling
- The Transplant Centre, Sahlgrenska University Hospital, Gothenburg S-413 45, Sweden
- Institute of Health and Care Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg S-405 30, Sweden
| | - Frank JMF Dor
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, London W2 1NY, United Kingdom
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7
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Gibbons A, Bayfield J, Cinnirella M, Draper H, Johnson RJ, Oniscu GC, Ravanan R, Tomson C, Roderick P, Metcalfe W, Forsythe JLR, Dudley C, Watson CJE, Bradley JA, Bradley C. Changes in quality of life (QoL) and other patient-reported outcome measures (PROMs) in living-donor and deceased-donor kidney transplant recipients and those awaiting transplantation in the UK ATTOM programme: a longitudinal cohort questionnaire survey with additional qualitative interviews. BMJ Open 2021; 11:e047263. [PMID: 33853805 PMCID: PMC8098938 DOI: 10.1136/bmjopen-2020-047263] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 01/13/2021] [Accepted: 01/22/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To examine quality of life (QoL) and other patient-reported outcome measures (PROMs) in kidney transplant recipients and those awaiting transplantation. DESIGN Longitudinal cohort questionnaire surveys and qualitative semi-structured interviews using thematic analysis with a pragmatic approach. SETTING Completion of generic and disease-specific PROMs at two time points, and telephone interviews with participants UK-wide. PARTICIPANTS 101 incident deceased-donor (DD) and 94 incident living-donor (LD) kidney transplant recipients, together with 165 patients on the waiting list (WL) from 18 UK centres recruited to the Access to Transplantation and Transplant Outcome Measures (ATTOM) programme completed PROMs at recruitment (November 2011 to March 2013) and 1 year follow-up. Forty-one of the 165 patients on the WL received a DD transplant and 26 received a LD transplant during the study period, completing PROMs initially as patients on the WL, and again 1 year post-transplant. A subsample of 10 LD and 10 DD recipients participated in qualitative semi-structured interviews. RESULTS LD recipients were younger, had more educational qualifications and more often received a transplant before dialysis. Controlling for these and other factors, cross-sectional analyses at 12 months post-transplant suggested better QoL, renal-dependent QoL and treatment satisfaction for LD than DD recipients. Patients on the WL reported worse outcomes compared with both transplant groups. However, longitudinal analyses (controlling for pre-transplant differences) showed that LD and DD recipients reported similarly improved health status and renal-dependent QoL (p<0.01) pre-transplant to post-transplant. Patients on the WL had worsened health status but no change in QoL. Qualitative analyses revealed transplant recipients' expectations influenced their recovery and satisfaction with transplant. CONCLUSIONS While cross-sectional analyses suggested LD kidney transplantation leads to better QoL and treatment satisfaction, longitudinal assessment showed similar QoL improvements in PROMs for both transplant groups, with better outcomes than for those still wait-listed. Regardless of transplant type, clinicians need to be aware that managing expectations is important for facilitating patients' adjustment post-transplant.
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Affiliation(s)
- Andrea Gibbons
- Department of Psychology, University of Winchester, Winchester, UK
- Health Psychology Research Unit, Royal Holloway University of London, Egham, UK
| | - Janet Bayfield
- Health Psychology Research Unit, Royal Holloway University of London, Egham, UK
- Health Psychology Research Unit, Health Psychology Research Ltd, Egham, UK
| | - Marco Cinnirella
- Department of Psychology, Royal Holloway, University of London, Egham, UK
| | - Heather Draper
- Health Sciences, University of Warwick, Warwick Medical School, Coventry, UK
| | - Rachel J Johnson
- Statistics and Clinical Studies, NHS Blood and Transplant, Bristol, UK
| | - Gabriel C Oniscu
- Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Rommel Ravanan
- Richard Bright Renal Unit, Southmead Hospital, Bristol, UK
| | - Charles Tomson
- Department of Renal Medicine, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Paul Roderick
- Academic Unit of Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Wendy Metcalfe
- Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - John L R Forsythe
- Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Edinburgh, UK
- Organ Donation and Transplantation, NHS Blood and Transplant Organ Donation and Transplantation Directorate, Bristol, UK
| | | | - Christopher J E Watson
- Department of Surgery, University of Cambridge, Cambridge, UK
- NIHR Cambridge Biomedical Research Centre and the NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - J Andrew Bradley
- Department of Surgery, University of Cambridge, Cambridge, UK
- NIHR Cambridge Biomedical Research Centre and the NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Clare Bradley
- Health Psychology Research Unit, Royal Holloway University of London, Egham, UK
- Health Psychology Research Unit, Health Psychology Research Ltd, Egham, UK
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8
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Kim JS, Marlais M, Balasubramanian R, Muorah M, Inward C, Smith GC, Reynolds BC, Yadav P, Morgan H, Shenoy M, Tse Y, Hussain F, Grylls S, Kessaris N, Sinha MD, Marks SD. UK national study of barriers to renal transplantation in children. Arch Dis Child 2021; 106:384-386. [PMID: 32241783 DOI: 10.1136/archdischild-2019-318272] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 03/19/2020] [Indexed: 11/04/2022]
Abstract
AIMS To investigate access to paediatric renal transplantation and examine potential barriers within the process. METHODS Cross-sectional, multicentre, observational study where paediatric nephrology centres in the UK were requested to provide data on transplantation plans for all children (<18 years) with end-stage kidney disease (ESKD). RESULTS 308 children with ESKD were included in this study from 12 out of 13 UK paediatric nephrology centres. 139 (45%) were being prepared for living donor transplantation and 82 (27%) were listed for deceased donor transplantation. The most common cited factors delaying transplantation from occurring in children were disease factors (36%), donor availability (27%) and size of the child (20%). Psychosocial factors were listed as a barrier in 19% of children. CONCLUSIONS In this study we have documented the main barriers to renal transplantation in children. Some identified factors may be modifiable through local or national intervention, including donor availability and patient psychosocial factors.
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Affiliation(s)
- Ji Soo Kim
- Paediatric Nephrology, Great Ormond Street Hospital For Children NHS Foundation Trust, London, UK .,Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Matko Marlais
- Paediatric Nephrology, Great Ormond Street Hospital For Children NHS Foundation Trust, London, UK.,Great Ormond Street Institute of Child Health, University College London, London, UK
| | | | - Mordi Muorah
- Paediatric Nephrology, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Carol Inward
- Paediatric Nephrology, Bristol Royal Hospital for Children, Bristol, UK
| | - Graham C Smith
- Paediatric Nephrology, Children's Hospital for Wales, Cardiff, UK
| | - Ben C Reynolds
- Paediatric Renal Unit, Royal Hospital for Children Glasgow, Glasgow, UK
| | - Pallavi Yadav
- Paediatric Nephrology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Henry Morgan
- Paediatric Nephrology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Mohan Shenoy
- Paediatric Nephrology, Royal Manchester Children's Hospital, Manchester, UK
| | - Yincent Tse
- Paediatric Nephrology, Great North Children's Hospital, Newcastle Upon Tyne, UK
| | - Farida Hussain
- Paediatric Nephrology, Nottingham Children's Hospital, Nottingham, UK
| | - Sarah Grylls
- Paediatric Nephrology, Southampton Children's Hospital, Southampton, UK
| | - Nicos Kessaris
- Paediatric Nephrology, Great Ormond Street Hospital For Children NHS Foundation Trust, London, UK.,Transplantation, Evelina London Children's Hospital, London, UK
| | - Manish D Sinha
- Paediatric Nephrology, Evelina London Children's Hospital, London, UK.,Child Health Clinical Academic Group, King's College London, London, UK
| | - Stephen D Marks
- Paediatric Nephrology, Great Ormond Street Hospital For Children NHS Foundation Trust, London, UK.,Great Ormond Street Institute of Child Health, University College London, London, UK
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9
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Nimmo A, Steenkamp R, Ravanan R, Taylor D. Do routine hospital data accurately record comorbidity in advanced kidney disease populations? A record linkage cohort study. BMC Nephrol 2021; 22:95. [PMID: 33731041 PMCID: PMC7968235 DOI: 10.1186/s12882-021-02301-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 03/02/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Routine healthcare datasets capturing clinical and administrative information are increasingly being used to examine health outcomes. The accuracy of such data is not clearly defined. We examine the accuracy of diagnosis recording in individuals with advanced chronic kidney disease using a routine healthcare dataset in England with comparison to information collected by trained research nurses. METHODS We linked records from the Access to Transplant and Transplant Outcome Measures study to the Hospital Episode Statistics dataset. International Classification of Diseases (ICD-10) and Office for Population Censuses and Surveys Classification of Interventions and Procedures (OPCS-4) codes were used to identify medical conditions from hospital data. The sensitivity, specificity, positive and negative predictive values were calculated for a range of diagnoses. RESULTS Comorbidity information was available in 96% of individuals prior to starting kidney replacement therapy. There was variation in the accuracy of individual medical conditions identified from the routine healthcare dataset. Sensitivity and positive predictive values ranged from 97.7 and 90.4% for diabetes and 82.6 and 82.9% for ischaemic heart disease to 44.2 and 28.4% for liver disease. CONCLUSIONS Routine healthcare datasets accurately capture certain conditions in an advanced chronic kidney disease population. They have potential for use within clinical and epidemiological research studies but are unlikely to be sufficient as a single resource for identifying a full spectrum of comorbidities.
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Affiliation(s)
- Ailish Nimmo
- Richard Bright Renal Service, Southmead Hospital, Bristol, BS10 5NB, UK.
| | | | - Rommel Ravanan
- Richard Bright Renal Service, Southmead Hospital, Bristol, BS10 5NB, UK
| | - Dominic Taylor
- Richard Bright Renal Service, Southmead Hospital, Bristol, BS10 5NB, UK
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10
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Manook M, Johnson R, Robb M, Burnapp L, Fuggle SV, Mamode N. Changing patterns of clinical decision making: are falling numbers of antibody incompatible transplants related to the increasing success of the UK Living Kidney Sharing Scheme? A national cohort study. Transpl Int 2020; 34:153-162. [PMID: 33095917 DOI: 10.1111/tri.13776] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 11/03/2019] [Accepted: 10/19/2020] [Indexed: 12/18/2022]
Abstract
Antibody incompatibility is a barrier to living kidney transplantation; antibody incompatible transplantation (AIT) is an accepted treatment modality, albeit higher risk. This study aims to determine changes to clinical decision making and access to AIT in the UK. An electronic survey was sent to all UK renal transplant centres (n = 24), in 2014, and again in 2018. Questions focused on entry & duration in the UKLKSS for HLA and ABO-incompatible pairs, Can and provision of direct AIT transplantation within those centres. Between 2014 & 2018, the duration recommended for patients in the UKLKSS increased. In 2014, 34.8% of centres reported leaving HLA-i pairs in the UKLKSS indefinitely, or reviewing on a case by case basis, by 2018 this increased to 61%. Centres offering direct HLA-i transplantation reduced from 58% to 37%. For low titre (1:8) ABO-i recipients, 66% of centres recommended at least 9 months (3 matching runs) in the UKLKSS scheme in 2018, compared to 47% in 2014, 50% fewer units consider direct ABO-i transplantation for unsuccessful pairs with high ABO titres (>1:512). Over time, clinicians appear to be facilitating more conservative management of AIT patients, potentially limiting access to living donor transplantation.
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Affiliation(s)
- Miriam Manook
- Renal and Transplant Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Rachel Johnson
- National Health Service Blood and Transplant (NHSBT), Bristol, UK
| | - Matthew Robb
- National Health Service Blood and Transplant (NHSBT), Bristol, UK
| | - Lisa Burnapp
- National Health Service Blood and Transplant (NHSBT), Bristol, UK
| | - Susan V Fuggle
- National Health Service Blood and Transplant (NHSBT), Bristol, UK
| | - Nizam Mamode
- Renal and Transplant Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
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A propensity score-matched analysis indicates screening for asymptomatic coronary artery disease does not predict cardiac events in kidney transplant recipients. Kidney Int 2020; 99:431-442. [PMID: 33171171 DOI: 10.1016/j.kint.2020.10.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 09/09/2020] [Accepted: 10/02/2020] [Indexed: 12/14/2022]
Abstract
Screening for asymptomatic coronary artery disease prior to kidney transplantation aims to reduce peri- and post-operative cardiac events. It is uncertain if this is achieved. Here, we investigated whether pre-transplant screening with a stress test or coronary angiogram associated with any difference in major adverse cardiac events (MACE) up to five years post-transplantation. We examined a national prospective cohort recruited to the Access to Transplant and Transplant Outcome Measures study who received a kidney transplant between 2011-2017, and linked patient demographics and details of cardiac screening investigations to outcome data extracted from the Hospital Episode Statistics dataset and United Kingdom Renal Registry. Propensity score matched groups were analyzed using Kaplan-Meier and Cox survival analyses. Overall, 2572 individuals were transplanted in 18 centers; 51% underwent screening and the proportion undergoing screening by center ranged from 5-100%. The incidence of MACE at 90 days, one and five years was 0.9%, 2.1% and 9.4% respectively. After propensity score matching based on the presence or absence of screening, 1760 individuals were examined (880 each in screened and unscreened groups). There was no statistically significant association between screening and MACE at 90 days (hazard ratio 0.80, 95% Confidence Interval 0.31-2.05), one year (1.12, 0.51-2.47) or five years (1.31, 0.86-1.99). Age, male sex and history of ischemic heart disease were associated with MACE. Thus, there is no association between screening for asymptomatic coronary artery disease and MACE up to five years post-transplant. Practices involving unselected screening of transplant recipients should be reviewed.
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Equity-Efficiency Trade-offs Associated With Alternative Approaches to Deceased Donor Kidney Allocation: A Patient-level Simulation. Transplantation 2020; 104:795-803. [PMID: 31403554 PMCID: PMC7147404 DOI: 10.1097/tp.0000000000002910] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Supplemental Digital Content is available in the text. Background. The number of patients waiting to receive a kidney transplant outstrips the supply of donor organs. We sought to quantify trade-offs associated with different approaches to deceased donor kidney allocation in terms of quality-adjusted life years (QALYs), costs, and access to transplantation. Methods. An individual patient simulation model was developed to compare 5 different approaches to kidney allocation, including the 2006 UK National Kidney Allocation Scheme (NKAS) and a QALY maximization approach designed to maximize health gains from a limited supply of donor organs. We used various sources of patient-level data to develop multivariable regression models to predict survival, health state utilities, and costs. We simulated the allocation of kidneys from 2200 deceased donors to a waiting list of 5500 patients and produced estimates of total lifetime costs and QALYs for each allocation scheme. Results. Among patients who received a transplant, the QALY maximization approach generated 48 045 QALYs and cost £681 million, while the 2006 NKAS generated 44 040 QALYs and cost £625 million. When also taking into consideration outcomes for patients who were not prioritized to receive a transplant, the 2006 NKAS produced higher total QALYs and costs and an incremental cost-effectiveness ratio of £110 741/QALY compared with the QALY maximization approach. Conclusions. Compared with the 2006 NKAS, a QALY maximization approach makes more efficient use of deceased donor kidneys but reduces access to transplantation for older patients and results in greater inequity in the distribution of health gains between patients who receive a transplant and patients who remain on the waiting list.
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Gibbons A, Cinnirella M, Bayfield J, Watson CJE, Oniscu GC, Draper H, Tomson CRV, Ravanan R, Johnson RJ, Forsythe J, Dudley C, Metcalfe W, Bradley JA, Bradley C. Changes in quality of life, health status and other patient‐reported outcomes following simultaneous pancreas and kidney transplantation (SPKT): a quantitative and qualitative analysis within a UK‐wide programme. Transpl Int 2020; 33:1230-1243. [DOI: 10.1111/tri.13677] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 02/10/2020] [Accepted: 06/12/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Andrea Gibbons
- Health Psychology Research Unit Royal Holloway University of London London UK
- Department of Psychology University of Winchester Winchester UK
| | - Marco Cinnirella
- Psychology Department Royal Holloway University of London London UK
| | - Janet Bayfield
- Health Psychology Research Unit Royal Holloway University of London London UK
| | - Christopher J. E. Watson
- Department of Surgery NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation University of Cambridge and the NIHR Cambridge Biomedical Research CentreUniversity of CambridgeAddenbrooke’s Hospital Cambridge UK
| | - Gabriel C. Oniscu
- Edinburgh Transplant Centre Royal Infirmary of Edinburgh Edinburgh UK
| | - Heather Draper
- Health Sciences Warwick Medical School University of Warwick Coventry UK
| | | | - Rommel Ravanan
- Richard Bright Renal Unit Southmead HospitalNorth Bristol NHS Trust Bristol UK
| | | | - John Forsythe
- Transplant Unit Royal Infirmary of Edinburgh Edinburgh UK
- Organ Donation and Transplantation NHS Blood and Transplant Bristol UK
| | - Chris Dudley
- Richard Bright Renal Unit Southmead HospitalNorth Bristol NHS Trust Bristol UK
| | - Wendy Metcalfe
- Edinburgh Transplant Centre Royal Infirmary of Edinburgh Edinburgh UK
| | - J. Andrew Bradley
- Department of Surgery NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation University of Cambridge and the NIHR Cambridge Biomedical Research CentreUniversity of CambridgeAddenbrooke’s Hospital Cambridge UK
| | - Clare Bradley
- Health Psychology Research Unit Royal Holloway University of London London UK
- Health Psychology Research Ltd Egham UK
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Pruthi R, Robb ML, Oniscu GC, Tomson C, Bradley A, Forsythe JL, Metcalfe W, Bradley C, Dudley C, Johnson RJ, Watson C, Draper H, Fogarty D, Ravanan R, Roderick PJ. Inequity in Access to Transplantation in the United Kingdom. Clin J Am Soc Nephrol 2020; 15:830-842. [PMID: 32467306 PMCID: PMC7274279 DOI: 10.2215/cjn.11460919] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 04/24/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND OBJECTIVES Despite the presence of a universal health care system, it is unclear if there is intercenter variation in access to kidney transplantation in the United Kingdom. This study aims to assess whether equity exists in access to kidney transplantation in the United Kingdom after adjustment for patient-specific factors and center practice patterns. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In this prospective, observational cohort study including all 71 United Kingdom kidney centers, incident RRT patients recruited between November 2011 and March 2013 as part of the Access to Transplantation and Transplant Outcome Measures study were analyzed to assess preemptive listing (n=2676) and listing within 2 years of starting dialysis (n=1970) by center. RESULTS Seven hundred and six participants (26%) were listed preemptively, whereas 585 (30%) were listed within 2 years of commencing dialysis. The interquartile range across centers was 6%-33% for preemptive listing and 25%-40% for listing after starting dialysis. Patient factors, including increasing age, most comorbidities, body mass index >35 kg/m2, and lower socioeconomic status, were associated with a lower likelihood of being listed and accounted for 89% and 97% of measured intercenter variation for preemptive listing and listing within 2 years of starting dialysis, respectively. Asian (odds ratio, 0.49; 95% confidence interval, 0.33 to 0.72) and Black (odds ratio, 0.43; 95% confidence interval, 0.26 to 0.71) participants were both associated with reduced access to preemptive listing; however Asian participants were associated with a higher likelihood of being listed after starting dialysis (odds ratio, 1.42; 95% confidence interval, 1.12 to 1.79). As for center factors, being registered at a transplanting center (odds ratio, 3.1; 95% confidence interval, 2.36 to 4.07) and a universal approach to discussing transplantation (odds ratio, 1.4; 95% confidence interval, 1.08 to 1.78) were associated with higher preemptive listing, whereas using a written protocol was associated negatively with listing within 2 years of starting dialysis (odds ratio, 0.7; 95% confidence interval, 0.58 to 0.9). CONCLUSIONS Patient case mix accounts for most of the intercenter variation seen in access to transplantation in the United Kingdom, with practice patterns also contributing some variation. Socioeconomic inequity exists despite having a universal health care system.
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Affiliation(s)
- Rishi Pruthi
- Transplant, Renal and Urology Directorate, Guy’s and St. Thomas’ National Health Service Foundation Trust, London, United Kingdom
- Academic Unit of Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Matthew L. Robb
- Statistics and Clinical Studies, National Health Service Blood and Transplant, Bristol, United Kingdom
| | - Gabriel C. Oniscu
- Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | | | - Andrew Bradley
- Department of Surgery, University of Cambridge and the National Institute for Health Research Cambridge Biomedical Research Centre, Cambridge, United Kingdom
| | - John L. Forsythe
- Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Wendy Metcalfe
- Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Clare Bradley
- Health Psychology Research Unit, Royal Holloway, University of London, Egham, United Kingdom
| | | | - Rachel J. Johnson
- Statistics and Clinical Studies, National Health Service Blood and Transplant, Bristol, United Kingdom
| | - Christopher Watson
- Department of Surgery, University of Cambridge and the National Institute for Health Research Cambridge Biomedical Research Centre, Cambridge, United Kingdom
| | - Heather Draper
- Department of Social Science and Systems in Health, University of Warwick, Coventry, United Kingdom
| | - Damian Fogarty
- Nephrology Unit, Belfast Health and Social Care Trust, Belfast, Northern Ireland, United Kingdom
| | - Rommel Ravanan
- Richard Bright Renal Unit, Southmead Hospital, Bristol, United Kingdom
| | - Paul J. Roderick
- Academic Unit of Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
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15
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Recipient Comorbidity and Survival Outcomes After Kidney Transplantation: A UK-wide Prospective Cohort Study. Transplantation 2020; 104:1246-1255. [DOI: 10.1097/tp.0000000000002931] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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16
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Burns T, Turner K, Brown M. Maximising access to kidney transplantation: A single-centre audit of people receiving dialysis. J Ren Care 2019; 45:248-256. [PMID: 31157954 DOI: 10.1111/jorc.12277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Revised: 02/09/2019] [Accepted: 03/17/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Despite transplantation being well documented as the renal replacement therapy option that gives the best morbidity and mortality outcomes, the best quality of life and the best value for healthcare dollar, not all patients are on a kidney transplant waiting list. OBJECTIVES The aims of this study were (1) to explore possible reasons for a demonstrated a higher rate of people being listed as suitable for transplant in a non-transplanting unit and (2) to describe a formal process of review and referral as a method for maximising the number of people gaining access to the transplant waiting list. METHODS We prospectively audited all patients who were undergoing dialysis in our metropolitan, non-transplanting renal unit annually over six years to determine whether not being on the transplant waiting list was in keeping with available eligibility guidelines of medical and behavioural criteria. RESULTS In every age group, the percentage of patients listed for transplant was higher than that seen in national data. The most common reasons for people not to be listed were malignancy, obesity and cardiovascular disease. This unit's patients had fewer smokers, less females and less Aboriginal and Torres Strait Islanders which may have contributed towards a higher rate of activation on the list. CONCLUSION In this dialysis patient population having a formal process of review for suitability and referral, as well as a specialist renal transplant coordinator nurse positively affected the number of patients being activated on the transplant waiting list.
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Affiliation(s)
- Tania Burns
- Renal Department, St George Hospital, Kogarah, New South Wales, Australia
| | - Kylie Turner
- Renal Department, St George Hospital, Kogarah, New South Wales, Australia
| | - Mark Brown
- Departments of Renal Medicine and Medicine, St George Hospital, University of New South Wales, Sydney, New South Wales, Australia
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17
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Limited health literacy is associated with reduced access to kidney transplantation. Kidney Int 2019; 95:1244-1252. [DOI: 10.1016/j.kint.2018.12.021] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 12/17/2018] [Accepted: 12/20/2018] [Indexed: 01/23/2023]
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18
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Williams A, Richardson C, McCready J, Anderson B, Khalil K, Tahir S, Nath J, Sharif A. Black Ethnicity is Not a Risk Factor for Mortality or Graft Loss After Kidney Transplant in the United Kingdom. EXP CLIN TRANSPLANT 2018; 16:682-689. [PMID: 30295582 DOI: 10.6002/ect.2018.0241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES There are conflicting reports in the literature regarding outcomes after kidney transplant for patients of black ethnicity. To investigate further, we compared outcomes for black versus white kidney transplant recipients in a single UK transplant center. MATERIALS AND METHODS We analyzed 1066 kidney transplant recipients (80 black patients, 986 white patients) within a single-center cohort (2007-2017) in the United Kingdom, with cumulative 4446 patient-year follow-up. Data were electronically extracted from the Department of Health Informatics database for every study recruit, with manual data linkage to the UK Transplant Registry (for graft survival, delayed graft function, and rejection data) and Office for National Statistics (for mortality data). Primary outcomes of interest were graft/patient survival. RESULTS Black recipients have increased baseline risk profiles with longer wait times, difficulty in matching, worse HLA matching, more socioeconomic deprivation, and lower rates of living kidney donors. Postoperatively, black versus white recipients had increased risk for delayed graft function (34.3% vs 10.2%; P < .001), increased 1-year rejection (16.7% vs 7.3%; P = .012), higher 1-year creatinine levels (166 vs 138 mmol/L; P = .003), and longer posttransplant length of stay (14.5 vs 9.5 days; P = .020). Although black recipients did not have increased risk of death versus white recipients (10.0% vs 11.0%, respectively; P = .486), they did have increased risk for death-censored graft loss (23.8% vs 11.1%; P = .002). However, in an adjusted Cox regression model, black ethnicity was not associated with increased risk for death-censored graft loss (hazard ratio of 1.209, 95% confidence interval, 0.660-2.216; P = .539). CONCLUSIONS Black kidney transplant recipients in the United Kingdom have increased risk of adverse graft-related outcomes due to high-risk baseline variables rather than their black ethnicity per se.
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Affiliation(s)
- Aimee Williams
- From the Department of Nephrology and Transplantation, Queen Elizabeth Hospital, Edgbaston, Birmingham, United Kingdom
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19
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Assessing Consensus Between UK Renal Clinicians on Listing for Kidney Transplantation: A Modified Delphi Study. Transplant Direct 2018; 4:e343. [PMID: 29796414 PMCID: PMC5959339 DOI: 10.1097/txd.0000000000000782] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 01/12/2018] [Indexed: 11/27/2022] Open
Abstract
Background It is well recognized that there is significant variation between centers in access to kidney transplantation. In the absence of high-grade evidence, it is unclear whether variation is due to patient case mix, other center factors, or individual clinician decisions. This study sought consensus between UK clinicians on factors that should influence access to kidney transplantation. Methods As part of the Access to Transplantation and Transplant Outcome Measures project, consultant nephrologists and transplant surgeons in 71 centers were invited to participate in a Delphi study involving 2 rounds. During rounds 1 and 2, participants rated their agreement to 29 statements covering 8 topics regarding kidney transplantation. A stakeholder meeting was used to discuss statements of interest after the 2 rounds. Results In total, 122 nephrologists and 16 transplant surgeons from 45 units participated in rounds 1 and 2. After 2 rounds, 12 of 29 statements reached consensus. Fifty people participated in the stakeholder meeting. After the stakeholder meeting, a further 4 statements reached agreement. Of the 8 topics covered, consensus was reached in 6: use of a transplant protocol, patient age, body mass index, patient compliance with treatment, cardiac workup, and use of multidisciplinary meetings. Consensus was not reached on screening for malignancy and use of peripheral Doppler studies. Conclusions The Delphi process identified factors upon which clinicians agreed and areas where consensus could not be achieved. The findings should inform national guidelines to support decision making in the absence of high quality evidence and to guide areas that warrant future research.
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Wu DA, Robb ML, Watson CJE, Forsythe JLR, Tomson CRV, Cairns J, Roderick P, Johnson RJ, Ravanan R, Fogarty D, Bradley C, Gibbons A, Metcalfe W, Draper H, Bradley AJ, Oniscu GC. Barriers to living donor kidney transplantation in the United Kingdom: a national observational study. Nephrol Dial Transplant 2018; 32:890-900. [PMID: 28379431 PMCID: PMC5427518 DOI: 10.1093/ndt/gfx036] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 02/09/2017] [Indexed: 02/06/2023] Open
Abstract
Background. Living donor kidney transplantation (LDKT) provides more timely access to transplantation and better clinical outcomes than deceased donor kidney transplantation (DDKT). This study investigated disparities in the utilization of LDKT in the UK. Methods. A total of 2055 adults undergoing kidney transplantation between November 2011 and March 2013 were prospectively recruited from all 23 UK transplant centres as part of the Access to Transplantation and Transplant Outcome Measures (ATTOM) study. Recipient variables independently associated with receipt of LDKT versus DDKT were identified. Results. Of the 2055 patients, 807 (39.3%) received LDKT and 1248 (60.7%) received DDKT. Multivariable modelling demonstrated a significant reduction in the likelihood of LDKT for older age {odds ratio [OR] 0.11 [95% confidence interval (CI) 0.08–0.17], P < 0.0001 for 65–75 years versus 18–34 years}; Asian ethnicity [OR 0.55 (95% CI 0.39–0.77), P = 0.0006 versus White]; Black ethnicity [OR 0.64 (95% CI 0.42–0.99), P = 0.047 versus White]; divorced, separated or widowed [OR 0.63 (95% CI 0.46–0.88), P = 0.030 versus married]; no qualifications [OR 0.55 (95% CI 0.42–0.74), P < 0.0001 versus higher education qualifications]; no car ownership [OR 0.51 (95% CI 0.37–0.72), P = 0.0001] and no home ownership [OR 0.65 (95% CI 0.85–0.79), P = 0.002]. The odds of LDKT varied significantly between countries in the UK. Conclusions. Among patients undergoing kidney transplantation in the UK, there are significant age, ethnic, socio-economic and geographic disparities in the utilization of LDKT. Further work is needed to explore the potential for targeted interventions to improve equity in living donor transplantation.
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Affiliation(s)
- Diana A Wu
- Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - Christopher J E Watson
- Department of Surgery, University of Cambridge and the NIHR Cambridge Biomedical Research Centre, Cambridge, UK
| | - John L R Forsythe
- Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, UK.,NHS Blood and Transplant, Bristol, UK
| | | | - John Cairns
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Paul Roderick
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | | | - Rommel Ravanan
- Department of Renal Medicine, Southmead Hospital, Bristol, UK
| | - Damian Fogarty
- Regional Nephrology and Transplant Centre, Belfast Health and Social Care Trust, Belfast, UK
| | - Clare Bradley
- Health Psychology Research Unit, Royal Holloway, University of London, Egham, UK
| | - Andrea Gibbons
- Health Psychology Research Unit, Royal Holloway, University of London, Egham, UK
| | - Wendy Metcalfe
- Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Heather Draper
- Health Sciences, University of Warwick, Conventry, UK (author has moved institutions since acceptance of the article)
| | - Andrew J Bradley
- Department of Surgery, University of Cambridge and the NIHR Cambridge Biomedical Research Centre, Cambridge, UK
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21
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Taylor DM, Bradley JA, Bradley C, Draper H, Johnson R, Metcalfe W, Oniscu G, Robb M, Tomson C, Watson C, Ravanan R, Roderick P. Limited health literacy in advanced kidney disease. Kidney Int 2017; 90:685-95. [PMID: 27521115 DOI: 10.1016/j.kint.2016.05.033] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 05/23/2016] [Accepted: 05/26/2016] [Indexed: 12/21/2022]
Abstract
Limited health literacy may reduce the ability of patients with advanced kidney disease to understand their disease and treatment and take part in shared decision making. In dialysis and transplant patients, limited health literacy has been associated with low socioeconomic status, comorbidity, and mortality. Here, we investigated the prevalence and associations of limited health literacy using data from the United Kingdom-wide Access to Transplantation and Transplant Outcome Measures (ATTOM) program. Incident dialysis, incident transplant, and transplant wait-listed patients ages 18 to 75 were recruited from 2011 to 2013 and data were collected from patient questionnaires and case notes. A score >2 in the Single-Item Literacy Screener was used to define limited health literacy. Univariate and multivariate analyses were performed to identify patient factors associated with limited health literacy. We studied 6842 patients, 2621 were incident dialysis, 1959 were wait-listed, and 2262 were incident transplant. Limited health literacy prevalence was 20%, 15%, and 12% in each group, respectively. Limited health literacy was independently associated with low socioeconomic status, poor English fluency, and comorbidity. However, transplant wait-listing, preemptive transplantation, and live-donor transplantation were associated with increasing health literacy.
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Affiliation(s)
- Dominic M Taylor
- Department of Primary Care and Population Sciences, University of Southampton, Southampton, UK; Richard Bright Renal Service, North Bristol National Health Service Trust, Bristol, UK.
| | - John A Bradley
- Department of Surgery, University of Cambridge, and National Institute for Health Research Cambridge Biomedical Research Centre, Cambridge, UK
| | - Clare Bradley
- Health Psychology Research Unit, Royal Holloway, University of London, London, UK
| | - Heather Draper
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | | | | | - Matthew Robb
- National Health Service Blood and Transplant, UK
| | - Charles Tomson
- Department of Renal Medicine, Freeman Hospital, Newcastle-upon Tyne, UK
| | - Chris Watson
- Department of Surgery, University of Cambridge, and National Institute for Health Research Cambridge Biomedical Research Centre, Cambridge, UK
| | - Rommel Ravanan
- Richard Bright Renal Service, North Bristol National Health Service Trust, Bristol, UK
| | - Paul Roderick
- Department of Primary Care and Population Sciences, University of Southampton, Southampton, UK
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Li B, Cairns JA, Draper H, Dudley C, Forsythe JL, Johnson RJ, Metcalfe W, Oniscu GC, Ravanan R, Robb ML, Roderick P, Tomson CR, Watson CJE, Bradley JA. Estimating Health-State Utility Values in Kidney Transplant Recipients and Waiting-List Patients Using the EQ-5D-5L. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2017; 20:976-984. [PMID: 28712628 PMCID: PMC5541449 DOI: 10.1016/j.jval.2017.01.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 11/22/2016] [Accepted: 01/27/2017] [Indexed: 05/11/2023]
Abstract
OBJECTIVES To report health-state utility values measured using the five-level EuroQol five-dimensional questionnaire (EQ-5D-5L) in a large sample of patients with end-stage renal disease and to explore how these values vary in relation to patient characteristics and treatment factors. METHODS As part of the prospective observational study entitled "Access to Transplantation and Transplant Outcome Measures," we captured information on patient characteristics and treatment factors in a cohort of incident kidney transplant recipients and a cohort of prevalent patients on the transplant waiting list in the United Kingdom. We assessed patients' health status using the EQ-5D-5L and conducted multivariable regression analyses of index scores. RESULTS EQ-5D-5L responses were available for 512 transplant recipients and 1704 waiting-list patients. Mean index scores were higher in transplant recipients at 6 months after transplant surgery (0.83) compared with patients on the waiting list (0.77). In combined regression analyses, a primary renal diagnosis of diabetes was associated with the largest decrement in utility scores. When separate regression models were fitted to each cohort, female gender and Asian ethnicity were associated with lower utility scores among waiting-list patients but not among transplant recipients. Among waiting-list patients, longer time spent on dialysis was also associated with poorer utility scores. When comorbidities were included, the presence of mental illness resulted in a utility decrement of 0.12 in both cohorts. CONCLUSIONS This study provides new insights into variations in health-state utility values from a single source that can be used to inform cost-effectiveness evaluations in patients with end-stage renal disease.
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Affiliation(s)
- Bernadette Li
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.
| | - John A Cairns
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Heather Draper
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | | | - John L Forsythe
- Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | | | | | - Rommel Ravanan
- Richard Bright Renal Unit, Southmead Hospital, Bristol, UK
| | | | - Paul Roderick
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Charles R Tomson
- Department of Renal Medicine, Freeman Hospital, Newcastle upon Tyne, UK
| | - Christopher J E Watson
- Department of Surgery, University of Cambridge and the NIHR Cambridge Biomedical Research Centre, Cambridge, UK
| | - J Andrew Bradley
- Department of Surgery, University of Cambridge and the NIHR Cambridge Biomedical Research Centre, Cambridge, UK
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McKane WS. Should Nephrologists Promote Peritoneal Dialysis as a Bridge to Transplantation? Perit Dial Int 2017; 37:247-249. [PMID: 28512161 DOI: 10.3747/pdi.2016.00269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- William S McKane
- Sheffield Kidney Institute, Northern General Hospital, Sheffield, UK
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24
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Manook M, Koeser L, Ahmed Z, Robb M, Johnson R, Shaw O, Kessaris N, Dorling A, Mamode N. Post-listing survival for highly sensitised patients on the UK kidney transplant waiting list: a matched cohort analysis. Lancet 2017; 389:727-734. [PMID: 28065559 DOI: 10.1016/s0140-6736(16)31595-1] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 07/28/2016] [Accepted: 08/30/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND More than 40% of patients awaiting a kidney transplant in the UK are sensitised with human leucocyte antigen (HLA) antibodies. Median time to transplantation for such patients is double that of unsensitised patients at about 74 months. Removing antibody to perform an HLA-incompatible (HLAi) living donor transplantation is perceived to be high risk, although patient survival data are limited. We compared survival of patients opting for an HLAi kidney transplant with that of similarly sensitised patients awaiting a compatible organ. METHODS From the UK adult kidney transplant waiting list, we selected crossmatch positive living donor HLAi kidney transplant recipients who received their transplant between Jan 1, 2007, and Dec 31, 2013, and were followed up to Dec 31, 2014 (end of study). These patients were matched in a 1:4 ratio with similarly sensitised patients cases listed for a deceased-donor transplant during that period. Data were censored both at the time of transplantation (listed only), and at the end of the study period (listed or transplant). We used Kaplan-Meier curves to compare patient survival between HLAi and the matched cohort. FINDINGS Of 25 518 patient listings, 213 (1%) underwent HLAi transplantation during the study period. 852 matched controls were identified, of whom 41% (95% CI 32-50) remained without a transplant at 58 months after matching. We noted no difference in survival between patients who were in the HLAi group compared with the listed only group (log rank p=0·446), or listed or transplant group (log rank p=0·984). INTERPRETATION Survival of sensitised patients undergoing HLAi in the UK is comparable with those on dialysis awaiting a compatible organ, many of whom are unlikely to be have a transplant. Choosing a direct HLAi transplant has no detrimental effect on survival, but offers no survival benefit, by contrast with similar patients studied in a North American multicentre cohort. FUNDING UK National Health Service Blood & Transplant and Guy's & St Thomas' National Institute for Health Research Biomedical Research Centre.
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Affiliation(s)
- Miriam Manook
- Department of Transplantation, Guy's and St Thomas' NHS Foundation Trust, Guy's Hospital, London, UK
| | - Leonardo Koeser
- King's Health Economics, Health Services and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience at King's College, London, UK
| | - Zubir Ahmed
- Department of Transplantation, Guy's and St Thomas' NHS Foundation Trust, Guy's Hospital, London, UK
| | | | | | - Olivia Shaw
- Clinical Transplantation Laboratory, Guy's & St Thomas' NHS Trust, Viapath, London, UK
| | - Nicos Kessaris
- Department of Transplantation, Guy's and St Thomas' NHS Foundation Trust, Guy's Hospital, London, UK
| | - Anthony Dorling
- Department of Transplantation, Guy's and St Thomas' NHS Foundation Trust, Guy's Hospital, London, UK; MRC Centre for Transplantation, King's College London, Guy's Hospital, London, UK
| | - Nizam Mamode
- Department of Transplantation, Guy's and St Thomas' NHS Foundation Trust, Guy's Hospital, London, UK.
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25
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Gibbons A, Cinnirella M, Bayfield J, Wu D, Draper H, Johnson RJ, Tomson CRV, Forsythe JLR, Metcalfe W, Fogarty D, Roderick P, Ravanan R, Oniscu GC, Watson CJE, Bradley JA, Bradley C. Patient preferences, knowledge and beliefs about kidney allocation: qualitative findings from the UK-wide ATTOM programme. BMJ Open 2017; 7:e013896. [PMID: 28132010 PMCID: PMC5278279 DOI: 10.1136/bmjopen-2016-013896] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To explore how patients who are wait-listed for or who have received a kidney transplant understand the current UK kidney allocation system, and their views on ways to allocate kidneys in the future. DESIGN Qualitative study using semistructured interviews and thematic analysis based on a pragmatic approach. PARTICIPANTS 10 deceased-donor kidney transplant recipients, 10 live-donor kidney transplant recipients, 12 participants currently wait-listed for a kidney transplant and 4 participants whose kidney transplant failed. SETTING Semistructured telephone interviews conducted with participants in their own homes across the UK. RESULTS Three main themes were identified: uncertainty of knowledge of the allocation scheme; evaluation of the system and participant suggestions for future allocation schemes. Most participants identified human leucocyte anitgen matching as a factor in determining kidney allocation, but were often uncertain of the accuracy of their knowledge. In the absence of information that would allow a full assessment, the majority of participants consider that the current system is effective. A minority of participants were concerned about the perceived lack of transparency of the general decision-making processes within the scheme. Most participants felt that people who are younger and those better matched to the donor kidney should be prioritised for kidney allocation, but in contrast to the current scheme, less priority was considered appropriate for longer waiting patients. Some non-medical themes were also discussed, such as whether parents of dependent children should be prioritised for allocation, and whether patients with substance abuse problems be deprioritised. CONCLUSIONS Our participants held differing views about the most important factors for kidney allocation, some of which were in contrast to the current scheme. Patient participation in reviewing future allocation policies will provide insight as to what is considered acceptable to patients and inform healthcare staff of the kinds of information patients would find most useful.
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Affiliation(s)
- Andrea Gibbons
- Health Psychology Research Unit, Royal Holloway University of London, Egham, UK
| | - Marco Cinnirella
- Department ofPsychology, Royal Holloway University of London, Egham, UK
| | - Janet Bayfield
- Health Psychology Research Unit, Royal Holloway University of London, Egham, UK
| | - Diana Wu
- Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Heather Draper
- Division of Health Sciences, Warwick Medical School, Coventry, UK
| | - Rachel J Johnson
- Statistics and Clinical Studies, NHS Blood and Transplant, Bristol, UK
| | | | - John L R Forsythe
- Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
- Organ Donation and Transplantation, NHS Blood and Transplant, Bristol, UK
| | - Wendy Metcalfe
- Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Damian Fogarty
- Regional Nephrology and Transplant Centre, Belfast Health and Social Care Trust, Belfast, UK
| | - Paul Roderick
- Academic Unit of Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Rommel Ravanan
- Department of Renal Medicine, Southmead Hospital, Bristol, UK
| | | | - Christopher J E Watson
- Department of Surgery, University of Cambridge, the NIHR Cambridge Biomedical Research Centre and the NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - J Andrew Bradley
- Department of Surgery, University of Cambridge, the NIHR Cambridge Biomedical Research Centre and the NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Clare Bradley
- Health Psychology Research Unit, Royal Holloway University of London, Egham, UK
- Health Psychology Research Ltd, Royal Holloway University of London, Egham, UK
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26
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Tambo E, Madjou G, Khayeka-Wandabwa C, Tekwu EN, Olalubi OA, Midzi N, Bengyella L, Adedeji AA, Ngogang JY. Can free open access resources strengthen knowledge-based emerging public health priorities, policies and programs in Africa? F1000Res 2016; 5:853. [PMID: 27508058 PMCID: PMC4955019 DOI: 10.12688/f1000research.8662.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/27/2016] [Indexed: 11/20/2022] Open
Abstract
Tackling emerging epidemics and infectious diseases burden in Africa requires increasing unrestricted open access and free use or reuse of regional and global policies reforms as well as timely communication capabilities and strategies. Promoting, scaling up data and information sharing between African researchers and international partners are of vital importance in accelerating open access at no cost. Free Open Access (FOA) health data and information acceptability, uptake tactics and sustainable mechanisms are urgently needed. These are critical in establishing real time and effective knowledge or evidence-based translation, proven and validated approaches, strategies and tools to strengthen and revamp health systems. As such, early and timely access to needed emerging public health information is meant to be instrumental and valuable for policy-makers, implementers, care providers, researchers, health-related institutions and stakeholders including populations when guiding health financing, and planning contextual programs.
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Affiliation(s)
- Ernest Tambo
- Department of Biochemistry and Pharmaceutical Sciences, Universite des Montagnes, Bangangté, Cameroon; Africa Disease Intelligence and Surveillance, Communication and Response (Africa DISCoR) Foundation, Yaoundé, Cameroon
| | - Ghislaine Madjou
- Africa Disease Intelligence and Surveillance, Communication and Response (Africa DISCoR) Foundation, Yaoundé, Cameroon
| | | | - Emmanuel N Tekwu
- Noguchi Memorial Institute for Medical Research (NMIMR), College of Health Science, University of Ghana, Greater Accra Region, Ghana
| | - Oluwasogo A Olalubi
- Department of Public Health, Kwara State University (KWASU), Malete, Kwara State, Nigeria
| | - Nicolas Midzi
- National Institute of Health Research, Harare, Zimbabwe
| | - Louis Bengyella
- Department of Biomedical Sciences, School of Basic and Biomedical Sciences, University of Health and Allied Sciences (UHAS), Ho, Volta Region, Ghana
| | - Ahmed A Adedeji
- Department of Pharmacology and Therapeutics, Kampala International University, Kansaga, Kampala, Uganda
| | - Jeanne Y Ngogang
- Service de Biochimie, Centre Hospitalier Universitaire (CHU), Yaoundé, Cameroon
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