Smoking is a risk factor for graft failure and mortality after renal transplantation

Impact of donor smoking history on kidney transplant recipient outcomes: A systematic review and meta-analysis

BACKGROUND

Impact of donor smoking history on kidney transplant recipient outcomes is undefined.

METHODS

We systematically searched, critically appraised, and summarized associations between donor smoking and primary outcomes of death-censored and all-cause graft failure (DCGF, ACGF), and secondary outcomes of allograft histology, delayed graft function, serum creatinine, estimated glomerular filtration rate, and mortality. We searched MEDLINE, Embase, and Cochrane Databases from 2000 to 2023. Risk of bias was assessed using Risk of Bias in Non-randomized Studies - of Exposure tool. Quality of evidence was assessed by Grading of Recommendations Assessment, Development and Evaluation Working Group recommendations. We pooled results using inverse variance, random-effects model and reported hazard ratios for time-to-event outcomes or binomial proportions. Statistical heterogeneity was assessed with I2 statistic.

RESULTS

From 1785 citations, we included 17 studies. Donor smoking was associated with modestly increased DCGF (HR 1.05 (95% CI: 1.01, 1.09); I2 = 0%; low quality of evidence), predominantly in deceased donors, and ACGF in adjusted analyses (HR 1.12 (95% CI: 1.06, 1.19); I2 = 20%; very low quality of evidence). Other outcomes could not be pooled meaningfully.

CONCLUSIONS

Kidney donor smoking history was associated with modestly increased risk of death-censored graft failure and all-cause graft failure. This review emphasizes the need for further research, standardized reporting, and thoughtful consideration of donor factors like smoking in clinical decision-making on kidney utilization and allocation.

Prevalence of Mental Disorders in a German Kidney Transplant Population: Results of a KTx360°-Substudy

In patients after kidney transplantation (KTx) an increased rate of affective and anxiety disorders has been observed. Repeatedly, a relationship between mental health issues and increased morbidity and mortality in KTx recipients has been reported. However, information on the prevalence of mental disorders in KTx patients is scarce. As part of the structured multimodal follow-up program (KTx360°), mental disorders were examined in 726 patients after KTx through structured diagnostic interviews using the Mini-DIPS Open Access. Overall, 27.5% had a current and 49.2% a lifetime mental disorder. Only 14.5% with a current mental disorder reported to be in treatment. Affected patients were younger, more often female, reported more symptoms of anxiety and depression and less perceived social support. While comparable to the rate in general population samples, the prevalence of mental disorders should attract attention. The low treatment rate requires an improved identification of afflicted patients and provision of specialist treatment.ISRCTN registry, https://doi.org/10.1186/ISRCTN29416382 , date of registry: 03.05.2017.

Age at Time of Kidney Transplantation as a Predictor for Mortality, Graft Loss and Self-Rated Health Status: Results From the Swiss Transplant Cohort Study

Introduction: The effect of age on health outcomes in kidney transplantation remains inconclusive. This study aimed to analyze the relationship between age at time of kidney transplantation with mortality, graft loss and self-rated health status in adult kidney transplant recipients.

Methods: This study used data from the Swiss Transplant Cohort Study and included prospective data of kidney transplant recipients between 2008 and 2017. Time-to-event analysis was performed using Cox’ regression analysis, and -in the case of graft loss- competing risk analysis. A random-intercept regression model was applied to analyse self-rated health status.

Results: We included 2,366 kidney transplant recipients. Age at transplantation linearly predicted mortality. It was also predictive for graft loss, though nonlinearly, showing that recipients aged between 35 and 55 years presented with the lowest risk of experiencing graft loss. No relationship of age with self-rated health status was detected.

Conclusion: Higher mortality in older recipients complies with data from the general population. The non-linear relationship between age and graft loss and the higher scored self-rated health status at all follow-up time-points compared to the pre-transplant status -regardless of age- highlight that age alone might not be an accurate measure for risk prediction and clinical decision making in kidney transplantation.

Nurse-led self-management support after organ transplantation-protocol of a multicentre, stepped-wedge randomized controlled trial

BACKGROUND

Recipients of an organ transplantation face a number of challenges and often need to change their health behaviour. Good self-management skills are essential for optimal clinical outcomes. However, few interventions are available to support post-transplant self-management. To fill this gap, we developed a self-management support intervention offered by nurse practitioners. The primary aim of the study is to implement and test the effectiveness of the ZENN intervention in promoting self-management skills among heart, kidney liver and lung transplant recipients in comparison to standard care. The secondary aim is to assess the self-management support skills of nurse practitioners who will deliver the intervention.

METHODS

This multi-centre stepped-wedge randomized controlled trial will take place from September 2020 until May 2023. All departments will commence with inclusion of patients in the control period. Each department will be randomly assigned to a start date (step in the wedge) to commence the experimental period. Patients in the control period will receive standard care and will be asked to complete questionnaires at baseline (T0), 6 months (T1) and 12 months (T2), to assess self-management, self-regulation, quality of life and adherence. During the experimental period, patients will receive standard care plus the ZENN intervention and receive the same set of questionnaires as participants in the control period. Nurse practitioners will complete a baseline and follow-up questionnaire to assess differences in self-management support skills. Video recordings of outpatient clinic consultations during the control and experimental periods will determine the differences in nurses' needs-thwarting and needs-supporting skills between the control and experimental period.

DISCUSSION

The ZENN intervention could be a useful approach to support patients' self-management skills after organ transplantation and thus promote clinical outcomes as well as avoid adverse events.

TRIAL REGISTRATION

Dutch Trial Register NL8469 . Registered on March 19, 2020.

How to manage cigarette smoking in kidney transplant candidates and recipients?

Tobacco smoking is a frequent problem affecting many kidney transplant (KT) candidates and recipients. The negative impact of active smoking on KT outcomes has been demonstrated. Consequently, most guidelines strongly recommend quitting smoking before considering kidney transplantation. However, nicotine addiction is a complex multifactorial disease and only 3–5% of the patients who try to quit by themselves achieve prolonged abstinence. Smoking cessation programmes (SCPs) have proven their efficacy in the general population to increase the rate of quitting and should therefore be proposed to all smoking KT candidates and recipients. Nevertheless, SCPs have not been evaluated in the KT field and not all KT centres have easy access to these programmes. In this work, we aim to review the current knowledge on the subject and provide an overview of the available interventions to help smoking patients quit. We detail non-pharmaceutical and pharmaceutical approaches and discuss their use in KT candidates and recipients.

Impact of recipient and donor smoking in living-donor kidney transplantation: a prospective multicenter cohort study

The smoking status of kidney transplant recipients and living donors has not been explored concurrently in a prospective study, and the synergistic adverse impact on outcomes remains uncertain. The self-reported smoking status and frequency were obtained from recipients and donors at the time of kidney transplantation in a prospective multicenter longitudinal cohort study (NCT02042963). Smoking status was categorized as "ever smoker" (current and former smokers collectively) or "never smoker." Among 858 eligible kidney transplant recipients and the 858 living donors, 389 (45.3%) and 241 (28.1%) recipients were considered ever smokers at the time of transplant. During the median follow-up period of 6 years, the rate of death-censored graft failure was significantly higher in ever-smoker recipients than in never-smoker recipients (adjusted HR, 2.82; 95% CI 1.01-7.87; P = 0.048). A smoking history of >20 pack-years was associated with a significantly higher rate of death-censored graft failure than a history of ≤20 pack-years (adjusted HR, 2.83; 95% CI 1.19-6.78; P = 0.019). No donor smoking effect was found in terms of graft survival. The smoking status of the recipients and donors or both did not affect the rate of biopsy-proven acute rejection, major adverse cardiac events, all-cause mortality, or post-transplant diabetes mellitus. Taken together, the recipient's smoking status before kidney transplantation is dose-dependently associated with impaired survival.

Working towards an ERAS Protocol for Pancreatic Transplantation: A Narrative Review

Enhanced recovery after surgery (ERAS) initially started in the early 2000s as a series of protocols to improve the perioperative care of surgical patients. They aimed to increase patient satisfaction while reducing postoperative complications and postoperative length of stay. Despite these protocols being widely adopted in many fields of surgery, they are yet to be adopted in pancreatic transplantation: a high-risk surgery with often prolonged length of postoperative stay and high rate of complications. We have analysed the literature in pancreatic and transplantation surgery to identify the necessary preoperative, intra-operative and postoperative components of an ERAS pathway in pancreas transplantation.

Comparison of a home-based (multi) systemic intervention to promoting Medication AdheRence and Self-management among kidney transplant recipients with care-as-usual: the MARS randomized controlled trial protocol

Background

After kidney transplantation non-adherence and inadequate self-management undermine clinical outcomes and quality of life. Both have been demonstrated to be substantial in all age groups. However, interventions promoting adherence and self-management among kidney transplant recipients that have proven to be effective are scarce. In this study we aim to develop and test an intervention to optimize adherence and self-management. In this article we describe the background and design of the trial entitled ‘promoting Medication AdheRence and Self-management among kidney transplant recipients’ (MARS-trial)’.

Methods/design

This is a single-center, parallel arm randomized controlled trial. Nonadherent kidney transplant recipients aged 12 years or older are eligible for inclusion. Patients will be randomly assigned to either the experimental or a control group. The control group will receive care-as-usual. The experimental group will receive care-as-usual plus the MARS-intervention. The MARS-intervention is an outreaching intervention, based on the principles of (multi) systemic therapy which means involving the social network. A standardized intervention protocol is used for consistency but we will tailor the behavior change techniques used to the specific needs and determinants of each patient. The primary outcome of medication adherence will be measured using electronic monitoring. Secondary outcome measures regarding medication adherence and self-management are also assessed. Data is collected at baseline (T0), after a run-in period (T1), at six months post-baseline/end of treatment (T2) and after a six month follow-up period (T3).

Discussion

We combined elements of (multi) systemic therapy and evidence-based behavior change techniques to create an outreaching and highly individualized intervention. In this trial we will investigate the impact on medication adherence and self-management after kidney transplantation.

Trial registration

Netherlands Trial Register,trial number NTR7462. Registered 7th September 2018, https://www.trialregister.nl/trial/7264

Cardiovascular risk factors and cardiovascular disease in patients with type 1 diabetes and end-stage renal disease candidates for kidney-pancreas transplantation: Trends from 1999 to 2017

AIMS

To evaluate the changes in cardiovascular risk factors (CVRFs) and cardiovascular disease (CVD) in patients with type 1 diabetes (T1D) and end-stage renal disease (ESRD) who were candidates for kidney-pancreas transplantation (KPTx) from 1999 to 2017.

METHODS

Patients with T1D referred for KPTx evaluation were included. The cohort was divided into five groups according to the year of evaluation (1999-2002, 2003-2006, 2007-2010, 2011-2014 and 2015-2017). The control of CVRFs and the prevalence of prior CVD were evaluated.

RESULTS

We evaluated 360 patients (64.4% men, age 38.9 ± 7.1 years). LDL-cholesterol <100 mg/dl increased from 22.7% to 76.9% (1999-2002 vs. 2015-2017; p < 0.001), as did the use of statins (from 24.7% to 74.5%; p < 0.001). Systolic blood pressure decreased from 138.8 ± 27.6 to 125.1 ± 27.9 mmHg (p = 0.001) and current smokers from 48% to 25% (p = 0.018). Intensive insulin treatment increased from 34.4% to 93.6% (p < 0.001). Diabetes duration before the initiation of renal replacement therapy increased from 23 ± 5.5 to 26.9 ± 8.9 years (p = 0.001). Overall, 30.3% had previous CVD, without significant changes over time (p = 0.699), albeit patients were older and had longer diabetes duration.

CONCLUSIONS

Patients with T1D and ESRD referred for KPTx have better control of CVRFs over time, which might lead to a decrease in cardiovascular events.

Effects of Smoking on Solid Organ Transplantation Outcomes

Tobacco smoking is the leading preventable cause of death worldwide. Both donor and recipient smoking have been shown to increase graft loss and mortality in solid organ transplant recipients in many studies. Only in lung transplants is smoking a universal contraindication to transplantation. Transplant centers implement different policies regarding smoking recipients and allografts from smoking donors. Due to scarcity of available allografts, the risks of smoking have to be weighed against the risks of a longer transplant waitlist period. Although transplant centers implement different strategies to encourage smoking cessation pre- and post-transplant, not many studies have been published that validate the efficacy of smoking cessation interventions in this vulnerable population. This article summarizes the results of studies investigating prevalence, impact on outcomes, and cessationinterventions for smoking in the transplant population. We report herein a review of the elevated risks of infection, malignancy, graft loss, cardiovascular events, and mortality in solid organ transplant populations.

A Nurse-Led Self-Management Support Intervention (ZENN) for Kidney Transplant Recipients Using Intervention Mapping: Protocol for a Mixed-Methods Feasibility Study

Background

Optimal self-management in kidney transplant recipients is essential for patient and graft survival, reducing comorbidity and health care costs while improving the quality of life. However, there are few effective interventions aimed at providing self-management support after kidney transplantation.

Objective

This study aims to systematically develop a nurse-led, self-management (support) intervention for kidney transplant recipients.

Methods

The Intervention Mapping protocol was used to develop an intervention that incorporates kidney transplant recipients’ and nurses’ needs, and theories as well as evidence-based methods. The needs of recipients and nurses were assessed by reviewing the literature, conducting focus groups, individual interviews, and observations (step 1). Based on the needs assessment, Self-Regulation Theory, and the “5A’s” model, change objectives were formulated (step 2). Evidence-based methods to achieve these objectives were selected and subsequently translated into practical implementation strategies (step 3). Then, program materials and protocols were developed accordingly (step 4). The implementation to test the feasibility and acceptability was scheduled for 2015-2017 (step 5). The last step of Intervention Mapping, evaluation of the intervention, falls outside the scope of this paper (step 6).

Results

The intervention was developed to optimize self-management (support) after kidney transplantation and targeted both kidney transplant recipients and nurse practitioners who delivered the intervention. The intervention was clustered into four 15-minute sessions that were combined with regular appointments at the outpatient clinic. Nurses received a training syllabus and were trained in communication techniques based on the principles of Solution-Focused Brief Therapy and Motivational Interviewing; this entailed guiding the patients to generate their own goals and solutions and focus on strengths and successes. Kidney transplant recipients were encouraged to assess self-management challenges using the Self-Management Web and subsequently develop specific goals, action plans, and pursuit skills to solve these challenges.

Conclusions

The Intervention Mapping protocol provided a rigorous framework to systematically develop a self-management intervention in which nurses and kidney transplant recipients’ needs, evidence-based methods, and theories were integrated.

International Registered Report Identifier (IRRID)

DERR1-10.2196/11856

Dietary Approach to Stop Hypertension (DASH) diet and risk of renal function decline and all-cause mortality in renal transplant recipients

Renal transplant recipients (RTR) are at risk of decline of graft function and premature mortality, with high blood pressure as an important risk factor for both. To study the association of the Dietary Approach to Stop Hypertension (DASH) diet with these adverse events, we conducted a prospective cohort study of adult RTR. Dietary data were collected using a validated 177-item food frequency questionnaire and an overall DASH-score was obtained. We included 632 stable RTR (mean ± standard deviation age 53.0 ± 12.7 years, 57% men). Mean DASH score was 23.8 ± 4.7. During median follow-up of 5.3 (interquartile range, 4.1-6.0) years, 119 (18.8%) RTR had renal function decline, defined as a combined endpoint of doubling of serum creatinine and death-censored graft failure, and 128 (20.3%) died. In Cox-regression analyses, RTR in the highest tertile of the DASH score had lower risk of both renal function decline (hazard ratio [HR] = 0.57; 95% confidence interval [CI], 0.33-0.96, P = .03) and all-cause mortality (HR = 0.52; 95%CI, 0.32-0.83, P = .006) compared to the lowest tertile, independent of potential confounders. Adherence to a DASH-style diet is associated with lower risk of both renal function decline and all-cause mortality. These results suggest that a healthful diet might benefit long-term outcome in RTR.

Smoking and outcomes in kidney transplant recipients: a post hoc survival analysis of the FAVORIT trial

Background

Tobacco use remains an international health problem with between 10% and 40% of adults currently using tobacco. Given the rising number of patients either awaiting or having received a kidney transplant and the absence of smoking cessation as the criterion for transplantation in guidelines, we explored the association between smoking status and clinical outcomes in kidney transplant recipients.

Patients and methods

In this post hoc analysis of the Folic Acid for Vascular Outcome Reduction in Transplant trial, the associations between smoking status, defined as never having smoked, formerly or currently smoking, and both all-cause mortality and graft survival were assessed using Cox proportional hazards models. Fatal events were centrally adjudicated into prespecified categories: all-cause, cardiovascular and non-cardiovascular causes. Graft loss was defined as return to dialysis or retransplantation. Clinical Trials URL: http://www.clinicaltrials.gov/show/NCT00064753.

Results

Among 4110 transplant recipients, there were 451 current smokers and 1611 former smokers. The mortality rate per 100 patient-years was 4.0 (71 deaths) for smokers, 3.5 (226 deaths) for former smokers and 2.4 (116 deaths) for never smokers. Hazard ratio for mortality for current smokers was 1.70 (CI=1.26–2.29, p=0.001) and for former smokers was 1.21 (0.98–1.50, p=0.08) with 1.0 representing never smokers. As the number of cardiovascular deaths was similar in each group (all p>0.3), the differences between groups was driven by non-cardiovascular death rates. Current smokers (2.39; 1.62–3.61, p<0.001) and former smokers (1.50; 1.12–2.01, p=0.007) had increased hazard of non-cardiovascular death. Kidney allograft failure was more likely in current smokers than in either former or never smokers (3.5, 2.1 and 2.0 per 100 patient-years, p<0.001, adjusted hazard ratio 1.49 and 1.05, respectively).

Conclusion

Continued smoking was associated with >100% increased risk of non-cardiovascular death, 70% greater risk of all-cause mortality and a 50% greater risk of graft loss, a risk not seen in former smokers. These findings confirm previous non-adjudicated observations that smoking is associated with adverse clinical outcomes and suggest that more emphasis should be placed on smoking cessation prior to kidney transplantation.

Smoking in Renal Transplantation; Facts Beyond Myth

Smoking is one of the preventable leading causes of death worldwide. Most of the studies focused on the association between smoking and cardiovascular disease, pulmonary diseases, malignancy and death. However, the direct effect of smoking on the renal system was undermind. There are emerging evidence correlating tobacco use with pathological changes in the normal kidneys. The effect is more obvious on the renal allograft most probably due to the chronic immune suppression status and the metabolic effect of the drugs. Several studies have documented a deleterious effect of smoking on the renal transplant recipients. Smoking was associated with lowering patient and graft survival. Smoking cessation proved to improve graft survival and to a lesser extent recipient survival. Even receiving a renal transplant from a smoker donor increases the risk of death for the recipient and carries a poorer graft survival compared to non-smoking donors. Most of the studies investigating the effect of smoking were based on self-reporting questioners, which may be misleading due to poor recall or the desire to give socially acceptable answers. This made the need of a reliable biomarker of ultimate importance. Cotinine was proposed as a promising biomarker that may help to provide objective evidence regarding the status of smoking and the dose of nicotine exposure, yet there are still some limitations of its use. The aim of this work is to review the current evidence to improve our understanding of this critical topic. Indeed, this will help to guide better-designed studies in the future.

Cigarette Smoking and Its Hazards in Kidney Transplantation

Cigarette smoking affects many organs. It causes vasoconstriction through activation of sympathetic nervous system which leads to elevation of blood pressure and reduction in glomerular filtration rate and filtration pressure. It also causes thickening of renal arterioles. Cigarette smoking increases the risk of microalbuminuria and accelerates progression of microalbuminuria to macroalbuminuria. Furthermore, it causes rapid loss of glomerular filtration rate in chronic kidney disease patients. After kidney donation, these factors may be injurious to the solitary kidney. Kidney donors with history of cigarette smoking are prone to develop perioperative complications, pneumonia, and wound infection. Postkidney transplantation various stressors including warm and cold ischemia time, delayed graft function, and exposure to calcineurin inhibitors may result in poor graft function. Continuation of cigarette smoking in kidney transplant recipients will add further risk. In this review, we will specifically discuss the effects of cigarette smoking on normal kidneys, live kidney donors, and kidney transplant recipients. This will include adverse effects of cigarette smoking on graft and patient survival, cardiovascular events, rejection, infections, and cancers in kidney transplant recipients. Lastly, the impact of kidney transplantation on behavior and smoking cessation will also be discussed.

Influence of Current and Previous Smoking on Cancer and Mortality After Kidney Transplantation

BACKGROUND

Evidence is limited regarding the effect of stopping smoking before kidney transplantation.

METHODS

Collaborative Transplant Study data from 46 548 recipients of first kidney transplants (1995-2012) were analyzed to 10 years after transplantation.

RESULTS

Compared with patients who had never smoked (n = 31,462), patients who stopped smoking before transplantation (n = 10,291) only had a modestly increased risk of all-cause graft failure (hazard ratio [HR], 1.1; 95% confidence interval [95% CI], 1.0-1.1; P < 0.001) or death (HR,1.1; 95% CI, 1.0-1.2; P < 0.001) and a similar risk of death-censored graft failure (HR,1.0, 95% CI, 1.0-1.1; P = 0.19), but a 40% increase in death from malignancy (HR, 1.4; 95% CI, 1.2-1.7; P < 0.001). The risk of events was generally markedly higher in patients who continued to smoke (n = 4795) versus those who had stopped. For tumors of the lip, oral cavity and pharynx, digestive organs, respiratory tract, female genitalia and urinary tract, HR values increased significantly from never-smoked to former smokers to current smokers. The risk of respiratory tumors or cervical cancer was approximately halved when smoking was stopped versus continued.

CONCLUSIONS

This large series provides clear evidence that patients who stop smoking before transplantation experience substantial benefits, including a substantial reduction in certain types of malignancy.

Attainment of the Elusive

Survival of a kidney transplant recipient beyond 2 decades is a relatively rare event. No studies have been conducted to describe individuals’ longevity attributions, who have had their kidney transplant for many years. The purpose of this qualitative analysis was to examine longevity attributions of kidney transplant recipients who have had a kidney transplant for 25 years or longer. The initial sample was obtained from an informal support group that includes only those who have had their kidney transplant >25 years. A semistructured 1-hour interview was conducted over the phone, audio-taped, and transcribed. Data were examined using thematic content analyses. The sample consisted of 19 participants (7 males and 12 females) ranging in age from 43 to 67 years, with a mean age of 52.8 years (standard deviation [SD] = 6.82). Transplants were performed between 26 and 36 years prior to the interviews, with a mean of 30.7 years (SD = 3.2). Emerging attributions included maintaining a healthy lifestyle, social support, positive attitude, faith, normalcy, participation in decision making, and luck. Prior to transplantation, patients were engaging in self-management behaviors, which many attributed to their success posttransplant. The findings of this study may provide insight and understanding for health-care providers and other transplant recipients regarding longevity attributions of those who have had their kidney transplants for over a quarter century. Future research should explore the impact of supporting kidney transplant recipients in self-management prior to and after transplantation.

A randomized clinical trial to determine the effectiveness of CO-oximetry and anti-smoking brief advice in a cohort of kidney transplant patients who smoke: study protocol for a randomized controlled trial

Background

The cardiovascular risk in renal transplant patients is increased in patients who continue to smoke after transplantation.

The aim of the study is to measure the effectiveness of exhaled carbon monoxide (CO) measurement plus brief advisory sessions, in comparison to brief advice, to reduce smoking exposure and smoking behavior in kidney transplant recipients who smoke. The effectiveness will be measured by: (1) abandonment of smoking, (2) increase in motivation to stop smoking, and (3) reduction in the number of cigarettes smoked per day.

Methods/design

Design: a randomized, controlled, open clinical trial with blinded evaluation.

Scope: A Coruña Hospital (Spain), reference to renal transplantation in the period 2012–2015.

Inclusion criteria: renal transplant patients who smoke in the precontemplation, contemplation or preparation stages according to the Prochaska and DiClemente’s Stages of Change model, and who give their consent to participate.

Exclusion criteria: smokers attempting to stop smoking, patients with terminal illness or mental disability that prevents them from participating.

Randomization: patients will be randomized to the control group (brief advisory session) or the intervention group (brief advisory session plus measuring exhaled CO). The sample target size is n = 112, with 56 patients in each group. Allowing for up to 10 % loss to follow-up, this would provide 80 % power to detect a 13 % difference in attempting to give up smoking outcomes at a two-tailed significance level of 5 %. Measurements: sociodemographic characteristics, cardiovascular risk factors, treatment, rejection episodes, infections, self-reported smoking habit, drug use, level of dependence (the Fagerström test), stage of change (Prochaska and DiClemente’s Stages of Change model), and motivation to giving up smoking (the Richmond test).

Response: the effectiveness will be evaluated every 3, 6, 9 and 12 months as: pattern of tobacco use (self-reported tobacco use), smoking cessation rates, carbon monoxide (CO) levels in exhaled air measured by CO-oximetry, urinary cotinine tests, nicotine dependence (Fagerström test), motivational stages of change (Prochaska and DiClemente’s stages) and motivation to stop smoking (the Richmond test).

Analysis: descriptive statistics and linear/logistic multiple regression models will be performed. Clinical relevance will be measured as relative risk reduction, absolute risk reduction and the number needed to treat.

Ethics: informed consent of the patients and Ethical Review Board was obtained (code 2011/061).

Discussion

Tobacco is a modifiable risk factor that increase the risk of morbidity and mortality in kidney transplant recipients. If effectiveness of CO-oximetry is confirmed to reduce tobacco exposure, we would have an intervention that is easy to use, low cost and with great implications about cardiovascular risk prevention in these patients.

Trial registration

Current Controlled Trials ISRCTN16615772.

EudraCT number: 2015-002009-12.

Assessment of Cotinine Reveals a Dose-Dependent Effect of Smoking Exposure on Long-term Outcomes After Renal Transplantation

BACKGROUND

Smoking is a risk factor for poor late outcomes in renal transplant recipients (RTR). Smoking exposure can be assessed by self-report and cotinine measurements. We investigated whether use of cotinine as a biomarker for smoking exposure can serve as an alternative for self-report and to compare associations of smoking exposure by self-report and cotinine with outcomes in RTR and assess dose dependency.

METHODS

Renal transplant recipients were classified as never, former, light (≤10 cigarettes/day), and heavy smokers (>10 cigarettes/day) according to self-report and analogous categories for urine and plasma cotinine. First, we assessed agreement of self-reported smoking exposure with smoking exposure according urine and plasma cotinine. Second, we compared the associations with graft failure and mortality.

RESULTS

Of 603 RTR (age 51.5 ± 12.1 years, 55% men), 36.0% RTR were never, 42.3% former, 10.6% light, and 11.1% heavy smokers according to self-report. The majority (98.6%) of never smokers had nondetectable cotinine. However, 14 and 13 RTR reporting no active smoking had respective urine or plasma cotinine consistent with active smoking. Cotinine-based measurements were dose-dependently associated with mortality and graft failure.

CONCLUSIONS

Plasma and urine cotinine can serve as an alternative to self-report and were dose-dependently associated with poor late outcomes in RTR.

Impact of patient characteristics and comorbidity profile on activation of patients on the kidney transplantation waiting list

BACKGROUND

The aim of this study was to examine which demographic and comorbidity factors affected the activation of patients with end-stage renal disease on the national kidney transplantation waiting list.

METHODS

This was a prospective cohort study across 13 transplantation centers in the United Kingdom from October 1, 2006 to September 30, 2007. Data were collected for all new adult patients (n = 1530) referred to the renal transplantation assessment clinic. The proportion of patients who were activated to the waiting list after a minimum one year follow-up was estimated. Factors influencing activation of patients on the waiting list were examined.

RESULTS

A total of 872 (58.9%) patients were activated to the transplantation waiting list. The likelihood of activation to the transplantation waiting list was lower in patients older than 65 years (P = .021), nonwhite ethnicity (P < .0001), smokers (P < .0001), and those in whom diabetes was the cause of renal failure (P = .004). Multivariate analysis showed that there was an adverse impact of comorbidity such as ischemic heart disease (P = .003), diabetes (P = .006), and peripheral vascular disease (P = .007) on the likelihood of activation to the waiting list.

CONCLUSION

Patient characteristics and comorbidity are associated with the probability of activation of patients to the waiting list.

Prevention of cardiovascular disease after renal transplantation

PURPOSE OF REVIEW

After renal transplantation, cardiovascular disease (CVD) is the leading cause of death with a functioning graft. Guidelines for prevention of CVD are mainly based on data from the general population. The purpose of this review is to give a practical approach on prevention of CVD in renal transplant recipients.

RECENT FINDINGS

New epidemiological data have shown that in addition to traditional risk factors for CVD, other risk factors may influence cardiovascular risk in renal transplant recipients. Recently, a specific risk calculator for CVD in renal transplant recipients has been developed. Prevention of CVD in renal transplant recipients should include lifestyle modifications, such as prevention of overweight, smoking cessation and physical exercise. Optimal treatment of hypertension, lipid disturbances and posttransplant diabetes should be encouraged. Accumulating evidence indicates that declining graft function and graft loss are potentially modifiable risk factors in this population, which make strategies for preserving graft function important. This situation may include individual tailoring of immunosuppression and use of new immunosuppressive medications with a more favorable effect on cardiovascular risk factors and graft function.

SUMMARY

To prevent CVD in renal transplant recipients, cardiovascular risk assessment should be performed regularly. Prevention should include both lifestyle modifications, optimal treatment of cardiovascular risk factors and strategies to preserve graft function.

[Kidney and smoking: literature review and focus]

Smoking remains a major public health problem. It is associated with a considerable number of deaths in the world's population. Smoking is just like high blood pressure, an independent predictor of progression to any primary renal disease and renal transplant patients. It seems that smoking cessation slows the progression of kidney disease in smokers. The literature data are sometimes contradictory about it because of some methodological weaknesses. However, experimental models highlight the harmful effects of tobacco by hemodynamic and non-hemodynamic factors. The conclusion is that a major effort should be further produced by the nephrology community to motivate our patients to stop smoking.

Previous exposure to cigarette smoke aggravates experimental cyclosporine-induced nephrotoxicity

BACKGROUND/AIMS

The effects of cigarette smoke (CS) on cyclosporine (CsA)-induced nephrotoxicity are poorly studied. This study aims to assess the effects of previous exposure to CS on CsA nephrotoxicity.

METHODS

Rats were either exposed to CS or sham (S) procedures for 10 min twice a day for 20 weeks. From the 16th to the 20th week, they received a low-salt diet. Beginning with the 17th week, they were given 2.5 mg/day CsA or vehicle (VH) for 3 weeks. The final groups were VH/CS, CsA/CS, VH/S, and CsA/S. On day 141, glomerular filtration rate (GFR), renal blood flow (RBF), renal vascular resistance (RVR), tubulointerstitial fibrosis, and CsA blood levels were measured and immunohistochemistry was analyzed for renal α-smooth muscle actin (SMA), nitrotyrosine, and vimentin.

RESULTS

CsA decrease in GFR was enhanced by CS exposure. CsA associated with CS induced higher periglomerular α-SMA and renal nitrotyrosine expression. CsA decreased RBF, but increased RVR, tubulointerstitial fibrosis, and α-SMA and renal vimentin expression. These changes and the CsA blood levels were not affected by CS exposure.

CONCLUSION

CS aggravated the CsA-induced impairment of GFR and CS associated with CsA caused the development of periglomerular structural lesions and oxidative stress in a rat model of CsA nephrotoxicity.

Renoprotective effects of long-term oral nicotine in a rat model of spontaneous proteinuria

Many proteinuric renal conditions are accompanied by renal inflammation. Nicotine is known to have anti-inflammatory properties and is used in oral form to help subjects quit smoking. A potential anti-inflammatory role of nicotine in proteinuric renal diseases has not been investigated to date. We therefore evaluated the effects of oral nicotine in a rat model of proteinuria-induced renal inflammation. We used a well-established model of adult (24 wk of age) male Munich-Wistar-Frömter rats. Animals were given three different physiological doses of nicotine in drinking water for 28 wk until 52 wk of age (long term). A group without nicotine served as a parallel control. At 52 wk of age, the control group had a 2.1 times reduction in creatinine clearance, 3.2 times increase in urinary protein excretion, an increased focal glomerulosclerosis (FGS) score, increased glomerular desmin deposition, decreased glomerular podocin, and a higher accumulation of macrophages and myofibroblasts compared with 24-wk-old animals. Oral treatment with nicotine dose dependently preserved renal function and halted proteinuria progression, which were independent of blood pressure reduction. It also reduced FGS, desmin deposition, podocin loss, and density of renal macrophages and myofibroblasts. Nicotine also reduced the level of gene expression of the renal inflammatory markers monocyte chemoattractant protein and vascular cell adhesion molecule-1. In conclusion, long-term oral nicotine preserved kidney function, reduced proteinuria, reduced renal inflammation, and protected progression of renal structural damage in a rat model of proteinuria. We further suggest evaluating nicotine as a potential additional therapeutic option for treating proteinuric kidney diseases.