Health-related quality of life outcomes after kidney transplantation

Differences in the epidemiology, management and outcomes of kidney disease in men and women

Improved understanding of differences in kidney disease epidemiology, management and outcomes in men and women could help nephrologists to better meet the needs of their patients from a sex- and gender-specific perspective. Evidence of sex differences in the risk and outcomes of acute kidney injury is mixed and dependent on aetiology. Women have a higher prevalence of chronic kidney disease (CKD) stages 3-5 than men, whereas men have a higher prevalence of albuminuria and hence CKD stages 1-2. Men show a faster decline in kidney function, progress more frequently to kidney failure and have higher mortality and risk of cardiovascular disease than women. However, the protective effect of female sex is reduced with CKD progression. Women are less likely than men to be aware of, screened for and diagnosed with CKD, started on antiproteinuric medication and referred to nephrologist care. They also consistently report a poorer health-related quality of life and a higher symptom burden than men. Women experience greater barriers than men to access the waiting list for kidney transplantation, particularly with respect to older age and obesity. However, women also have longer survival than men after transplantation, which may partly explain the comparable prevalence of transplantation between the sexes.

Psychosocial determinants of healthcare use costs in kidney transplant recipients

Introduction

Psychosocial factors frequently occur in kidney transplant recipients (KTRs), leading to behavioral alterations and reduced therapeutic adherence. However, the burden of psychosocial disorders on costs for KTRs is unknown. The aim of the study is to identify predictors of healthcare costs due to hospital admissions and emergency department access in KTRs.

Methods

This is a longitudinal observational study conducted on KTRs aged >18 years, excluding patients with an insufficient level of autonomy and cognitive disorder. KTRs underwent psychosocial assessment via two interviews, namely the Mini-International Neuropsychiatric Interview 6.0 (MINI 6.0) and the Diagnostic Criteria for Psychosomatic Research Interview (DCPR) and via the Edmonton Symptom Assessment System Revised (ESAS-R) scale, a self-administrated questionnaire. Sociodemographic data and healthcare costs for hospital admissions and emergency department access were collected in the 2016-2021 period. Psychosocial determinants were as follows: (1) ESAS-R psychological and physical score; (2) symptomatic clusters determined by DCPR (illness behavior cluster, somatization cluster, and personological cluster); and (3) ICD diagnosis of adjustment disorder, anxiety disorder, and mood disorder. A multivariate regression model was used to test the association between psychosocial determinants and total healthcare costs.

Results

A total of 134 KTRs were enrolled, of whom 90 (67%) were men with a mean age of 56 years. A preliminary analysis of healthcare costs highlighted that higher healthcare costs are correlated with worse outcomes and death (p < 0.001). Somatization clusters (p = 0.020) and mood disorder (p < 0.001) were positively associated with costs due to total healthcare costs.

Conclusions

This study showed somatization and mood disorders could predict costs for hospital admissions and emergency department access and be possible risk factors for poor outcomes, including death, in KTRs.

A drug utilization and drug interaction study in renal transplant patients: Implications for an urgent need for drug deprescribing

BACKGROUND: Renal transplant patients receive several drugs concomitantly. OBJECTIVE: Limited literature exists evaluating the drug use in this population that is at high risk for drug-induced acute kidney injury and complications due to under-or over-dosage of immunosuppressant drugs due to drug–drug interactions. METHODS: A retrospective observational study was carried out in 269 renal transplant patients in whom either oral or parenteral drugs were evaluated. World Health Organization (WHO) indicators of drug utilization such as the average number of drugs prescribed, daily defined dose, and proportion of drugs listed as WHO essential drugs were evaluated. Details on the drugs with nephrotoxic potential were obtained. Drug–drug interactions were assessed concerning the severity (major, moderate, and minor) as well as type (pharmacokinetic, pharmacodynamic, and toxicity). RESULTS: One-hundred and ninety-eight drugs were administered to the study participants. The median (range) total number of drugs received by the study participants was 23 (6–55). The proportion of drugs listed in the WHO essential drug database was 57.1 (16.7–100)%. Forty-six drugs with potential nephrotoxicity and seven drugs that were contra-indicated in patients with chronic renal disease/end-stage renal disease were administered to the study participants. The mean (SD) numbers of drug interactions observed amongst the study participants were 18.4 (10.1). Age (β: 0.2, 95% CI: 0.1, 0.3) and duration of renal transplantation (β: −0.3, 95% CI: −0.5, −0.1) were the significant predictors of drug burden. A total of 645 drug interactions were identified amongst the study participants (major – 240; moderate – 270; and minor – 135) of which the majority were pharmacokinetic followed by toxicity risk. Age was significantly associated with the risk of potential drug interaction (OR: 2.6, 95% CI: 1.8, 12.4; p = 0.001). CONCLUSION: Drug treatment in renal transplant patients poses a significant burden in terms of nephrotoxicity potential and drug–drug interactions. A dedicated ambulatory clinical pharmacy service monitoring the drug use coupled with drug deprescribing strategies are the need of the hour in this population.

Adherence to Immunosuppressive Therapies after Kidney Transplantation from a Biopsychosocial Perspective: A Cross-Sectional Study

Kidney transplantation (KT) is the best method for kidney replacement therapy (KRT) because of patient survival rates and quality of life (QoL). Nowadays, the main cause of graft loss is antibody-mediated rejection. The treatment of humoral injury is difficult with uncertain results and still not firmly established. Therefore, appropriate adherence is crucial to prolong graft and patient survival. This study aims to evaluate the association of transplant patients’ acceptance of illness, symptoms of anxiety and depression, frailty, and QoL with medication adherence in KT recipients. A total of 210 patients after KT completed the surveys. The instruments were distributed during patients’ admission at the clinic by a qualified nurse, who assisted the patients’ in completing the questionnaires. A cross-sectional study of KT recipients 9.45 ± 7.26 years after KT was performed. Patient adherence with medications was assessed using the Adherence to Refills and Medications Scale (ARMS). Explanatory variables were examined with validated instruments, such as the World Health Organization Quality of Life (WHOQoL-BREF) questionnaire, The Mini-Mental State Examination (MMSE), the Acceptance of Illness Scale (AIS), the Hospital Anxiety and Depression Scale (HADS), and the Tilburg Frailty Indicator (TFI) scale, respectively. Simple linear and multiple regression analyses demonstrated the positive correlation between acceptance of illness and adherence to immunosuppressive medications in a patient sample of KT recipients. The other important factor facilitating adherence to medications was linked with physical and environmental dimensions. On the other hand, frail kidney transplant patients were more likely to be non-adherent. In conclusion, identifying contributors to better medication adherence in immunosuppressive therapy is crucial in preventing transplant rejection or graft loss. In the kidney transplant population, the acceptance of illness, selected dimensions of QoL, and demographic variables associated with rural living and vocational education favored adherence behaviors.

ssessment of Tacrolimus Neurotoxicity Measured by Retinal OCT

BACKGROUND

Neurotoxicity secondary to anticalcineurinics is a prevalent side effect in transplant recipients. Optical coherence tomography (OCT) scans the central nervous system by direct access to the retina. OCT assesses central nervous system involvement by measuring the thickness of the retinal layers, especially the ganglion cell layer (GCL). The retinal scan divides the scanned area into affected and unaffected segments, which can be quantified for each eye. The aim of this study was to determine retinal GCL thickness by means of OCT, analyzing the proportion of affected segments in individuals exposed to tacrolimus compared with a control group.

MATERIALS AND METHODS

We evaluated 20 renal transplant recipients exposed to tacrolimus for ≥6 months. The number of affected segments in the GCL of the retina was quantified by OCT. The control group was drawn from the general population attending routine ophthalmologic checkups.

RESULTS

Patients exposed to tacrolimus had a pathologic examination in 50% of cases compared with 20% in the control group (P < .044). Furthermore, among patients with an exposure time to tacrolimus >5 years, the examination was pathologic in 80% (P < .005). Linear regression analysis showed the presence of GCL segments with decreased thickness to be associated with the duration of exposure to tacrolimus (P = .036) and the time in dialysis before kidney transplant (P = .030).

CONCLUSION

Although this is a preliminary study, OCT scanning could serve to detect the neurotoxic effect of tacrolimus on the retinal GCL and central nervous system in renal transplant recipients.

Acute Esophageal Necrosis Early after Renal Transplantation

Background

Acute esophageal necrosis (AEN) is defined as a diffused black discoloration of the esophageal mucosa involving mainly the distal part of the esophagus. It is considered a rare clinical entity with a high mortality rate. The etiology of AEN is unknown, but it has been correlated to many causes such as malignancies, infections, and hemodynamics instability. Here, we report a case of a patient developing AEN a few days after kidney transplantation. Case Presentation. A 57-year-old male was admitted electively for kidney transplantation that he received from his son. The surgery was complicated with a significant drop in blood pressure but otherwise was uneventful. The patient was showing good signs of recovery but then suffered from significant hematemesis. An urgent upper esophagogastroduodenoscopy revealed black discoloration of the esophageal mucosa in keeping with AEN. The patient was treated with proton pump inhibitors infusion and started empirically on antivirals and antifungals. The patient's condition improved in regards to the AEN; nonetheless, the complications resulted in graft loss, and the patient returned to hemodialysis.

Conclusion

AEN is a critical condition that mandates early intervention. Identifying high-risk populations may aid in early anticipation and diagnosis. Patients with chronic kidney disease are at risk of atherosclerosis leading to a low flow state which is exacerbated during renal transplantation surgery, especially if the procedure was complicated with a drop in blood pressure.

HLA-G 14bp Ins/Del Polymorphism in the 3'UTR Region and Acute Rejection in Kidney Transplant Recipients: An Updated Meta-Analysis

Background and Objectives: Acute kidney injury (AKI) affects the survival rate of kidney transplant organs and patients. Acute rejection (AR) due to AKI may lead to kidney transplantation failure. It is known that there is a relationship between human leukocyte antigen-G (HLA-G), which is involved in immune regulation, and AR in transplant patients. Moreover, 14-bp insertion/deletion polymorphism in the 3' untranslated region (UTR) region of the HLA-G gene is known to affect HLA-G expression. However, its relationship to AR is still controversial. The aim of this study was to investigate whether HLA-G 14-bp insertion/deletion polymorphism contributed to the development of AR in kidney transplant patients using a meta-analysis. Materials and Methods: To perform our meta-analysis, eligible studies about HLA-G 14-bp insertion/deletion polymorphism and AR were searched in electronic databases until 1 June 2021. Finally, a total of 336 patients with AR and 952 patients without AR in relation to kidney transplantation were analyzed from a total of nine studies. Results: In our results, the Del allele and Ins/Del+Del/Del and Del/Del genotypes significantly increased susceptibility of AR in Asian populations [odds ratio (OR) = 2.359, 95% confidence interval (CI) = 1.568-3.550, p = 3.8 × 10^-5; OR = 3.357, 95% CI = 1.769-6.370, p = 0.002; OR = 2.750, 95% CI = 1.354-5.587, p = 0.0052 in each model, respectively]. Conclusions: Evidence of the present results indicate that HLA-G 14-bp insertion/deletion polymorphism is associated with susceptibility to AR in the Asian population.

Measuring Health-Related Quality of Life in Vietnamese Patients After Kidney Transplantation

Objectives: To consider that the health-related quality of life (HRQOL) has become an inherent part of the patient outcomes in the care and treatment after kidney transplantation (KT). This study aimed to measure HRQOL among a representative sample size of patients after KT by using both the Short Form 36 (SF-36) and the Kidney Disease Quality of Life 36 (KDQOL-36). Methods and Results: Data of this cross-sectional design were collected in the Organ Transplant Center, Viet Duc University Hospital (Hanoi, Vietnam) from January 2020 to March 2020 and included the patients aged 18 years or over after KT at 6 months, 1 year, and 3 years postoperatively. HRQOL was evaluated through face-to-face interviews by means of the SF-36 and KDQOL-36 measurement tools. According to the SF-36, the overall mean score of HRQOL was 69.13 ± 15.55 and the two domains were the highest scores of "Mental Health" (81.23 ± 14.28) and "General Health" (80.06 ± 14.81). When measuring with the KDQOL-36, the overall mean score was 68.67 ± 13.75 and was the highest in the domain "Symptoms and Problems of Kidney Disease" (87.06 ± 16.00). Both instruments had good reliability for those after KT. The reliability of the SF-36 was high with Cronbach's coefficients α = 0.90. There were positive relationships between the dimensions measured by the KDQOL-36 and SF-36 (correlation coefficient: 0.03-0.69). Similarly, the domains of the SF-36 also had positive correlations with the KDQOL-36 (correlation coefficient: 0.18-0.51). The correlation coefficient between overall HRQOL scores of the SF-36 and KDQOL-36 was 0.62, indicating a strong correlation between the SF-36 and KDQOL-36. Conclusions: There were slight fluctuations in the HRQOL score in domains in the 3-year follow-up stages, suggesting not having clear change. The mean SF-36 score was consistent with the mean KDQOL-36 score. High reliability and strong correlation were found between two instruments of the SF-36 and KDQOL-36. This study provides the reliability and constructs validity in the combination of two sets of the SF-36 and KDQOL-36 scales for the assessment of HRQOL among post-KT patients, thereby assisting physicians and health professionals in the clinical decision-making, assessment of therapeutic efficacy, and understanding of treatment risk.

Análisis comparativo entre la calidad de vida del paciente trasplantado renal y el paciente en hemodiálisis

Objetivo: El objetivo del presente estudio fue comparar la calidad de vida relacionada con la salud del paciente trasplantado renal frente al paciente en hemodiálisis. Material y Método: Estudio observacional comparativo por emparejamiento (1:2) en 240 pacientes (80 en hemodiálisis y 160 trasplantados renales). El muestreo fue no probabilístico intencionado por emparejamiento. El emparejamiento se realizó por: edad, sexo y comorbilidad. Se utilizó el cuestionario KDQOL-SF para analizar calidad de vida relacionada con la salud. Resultados: Los pacientes tenían una edad de 59,80±12,45 años. Los pacientes trasplantados presentaron mejores puntuaciones, con diferencias significativas, en todas las dimensiones de las Escalas específicas para las enfermedades renales, excepto en el Apoyo Social. De igual forma, puntuaron mejor con diferencias significativas, los pacientes trasplantados en todas las dimensiones en el cuestionario SF-36. Los pacientes diabéticos trasplantados puntuaron peor en las dimensiones Carga de la enfermedad renal y Dolor; y los pacientes diabéticos en diálisis, en el Rol emocional. En el grupo de trasplantados, las mujeres puntuaron peor de forma significativa, en las dimensiones Listado de síntomas/problemas, Efectos de la enfermedad, Dolor y Vitalidad; y el grupo de pacientes en hemodiálisis, las mujeres puntuaron peor en la Función física. Conclusiones: Emparejados por edad, sexo y diabetes, los pacientes trasplantados renales presentan mejor calidad de vida relacionada con la salud que los pacientes en hemodiálisis, tanto en las Escalas específicas para la enfermedad renal como en las dimensiones del SF-36. En ambos grupos, los pacientes diabéticos presentan peor calidad de vida que los no diabéticos.

Quality of Life and Health Status Among Patients Receiving Renal Replacement Therapy in Trinidad and Tobago, West Indies

PURPOSE

The determinants of quality of life for patients on renal replacement therapy vary across the world. The aim of this study is to determine the quality of life of patients on renal replacement therapy in Trinidad and Tobago and predictors thereof.

PATIENTS AND METHODS

This cross-sectional study took place over a 1-year period. Data were obtained from 530 out of 1383 patients meeting inclusion criteria (100 transplants, 80 peritoneal dialyses, 350 hemodialyses) using the survey instruments. Stratified random sampling with proportional allocation was used to select patients at hemodialysis centres. The Kidney Disease Quality of Life questionnaire (KDQOL-36), EuroQol and demographic questionnaires were administered via face-to-face interviews. SPSS24, STATA14 and MINITAB18 were used for descriptive and inferential data analysis.

RESULTS

Of the 530 patients, 52.5% were male, 37.5% were in the 56-65 years age group and 51.3% were of Indo-Trinbagonian descent. Hypertension (25.5%) and type 2 diabetes mellitus (62.0%) were reported as the main causes of kidney disease in the dialysis group. In the transplant category, chronic glomerulonephritis (45%) was the main aetiology of kidney disease. The KDQOL-36 domain scores and significantly associated variables included modality of renal replacement, Charlson's Comorbidity Index, ethnicity, income and employment status. Transplant patients had higher mean subcomponent Kidney Disease Quality of Life scores and performed better in the EuroQol than patients on dialysis. Patients on peritoneal dialysis had a better quality of life than hemodialysis patients. Among patients on hemodialysis, an arteriovenous fistula significantly impacted their quality of life.

CONCLUSION

Renal transplant recipients enjoy the best quality of life and health state among patients on renal replacement therapy in Trinidad and Tobago. Increasing patients' access to renal transplantation or peritoneal dialysis will markedly improve health status for the number of years of renal replacement therapy.

Quality of life for kidney transplant palestinian patients

The purpose of kidney transplantation is to improve the quality of life (QoL) for patients with end-stage renal disease. This study aims to measure QoL in renal transplant patients in Bethlehem and Hebron in Palestine. A descriptive, cross-sectional study was performed on 109 renal transplant patients referred to Palestinian Ministry of Health - primary health-care clinics of Bethlehem and Hebron in Palestine from December 2016 to April 2017, by using Kidney Transplant Questionnaire (KTQ-25) for the assessment of QoL and determining the effect of sociodemographic variables on QoL. The reliability of KTQ-25 was determined to be 0.74 by Cronbach's alpha method. Data were analyzed by Statistical Package for Social Sciences version 19.0 and descriptive analytic statistics. The mean QoL for kidney transplant patients was 4.02 ± 0.84. The highest score of the KTQ was the appearance dimension (5.40 ± 1.23), whereas the lowest was related to the uncertainty/fear dimension (3.36 ± 1.23). The sample consisted of mostly males (79.8%), and their mean age was (41 ± 24) years. Most were married (81.7%), 45.9% were without work, and 66.1% of kidney donors' type were biologically blood related. No statistically significant difference was observed (P ≥ 0.05) between the sociodemographic variables and QoL. Surprisingly, the majority of kidney transplant patients (83.3%) were on prednisone. The QoL for kidney transplant patients was moderate. The society, government, family, and medical staff need to support patients to alleviate fear and uncertainty they feel. Furthermore, high reliance on corticosteroids in treatment needs to be reconsidered.

The impact of pain on the quality of life of patients with end-stage renal disease undergoing hemodialysis: a multicenter cross-sectional study from Palestine

BACKGROUND

Chronic kidney disease is considered as a global health problem. Hemodialysis (HD), following renal transplantation, is the most common form of renal replacement therapy. However, HD may impact the quality of life (QOL). Pain is a frequent complaint among this population that also affects their QOL. The purposes of this study were to assess pain and QOL among end-stage renal disease (ESRD) patients on HD and to examine their association.

METHODS

This was a multicenter, cross-sectional study that occurred in Palestine between August and November 2018. Brief Pain Inventory and European Quality of Life scale 5 dimensions (EQ-5D) scale, including its European Quality of Life visual analogue scale (EQ-VAS) component, were used to assess pain and QOL, respectively.

RESULTS

A total of 300 participants were included in the final study. The average age of the subjects was 54 ± 16 years. Their median EQ-5D score was 0.68 [0.54-0.88], whereas their median EQ-VAS score was 60 [40-75]. A statistically significant association of pain severity score with EQ-5D score was found (r = - 0.783, p < 0.001). The association between pain interference score and EQ-5D score was also found to be statistically significant (r = - 0.868, p < 0.001). Similarly, pain severity score was significantly assocsiated with EQ-VAS score (r = - 0.590, p < 0.001), the same as was the pain interference score (r = - 0.647, p < 0.001). Moreover, age, gender, BMI, employment, educational level, income level, dialysis vintage, previous kidney transplantation, and chronic medication use were all significantly correlated with QOL. Regression analysis showed that patients aged < 60 years (p < 0.001), those with lower pain severity scores (p = 0.003), and those with lower pain interference scores (p < 0.001) had significantly higher QOL scores.

CONCLUSIONS

Pain has a significant negative impact on QOL in ESRD patients undergoing HD. The subgroups that were at higher risk included elderly patients, females, those with higher BMI, those without a formal education, those unemployed, those living with low monthly income, smokers, those who have multiple comorbidities, and patients with longer dialysis vintage. Our findings provide reliable data for educators and clinicians working with HD patients.

Physical Function in Kidney Transplantation: Current Knowledge and Future Directions

Purpose of review

Low physical function (PF) is common among individuals with end-stage kidney disease. In this review, we explore data on the impacts of PF on access to kidney transplantation (KT) and KT outcomes. We also discuss the latest interventions to improve PF in pre- and post-KT settings.

Recent Findings

Many US KT programs measure PF or related constructs when assessing KT candidacy. Although carefully selected KT candidates with low PF can benefit from KT with respect to survival and quality of life, low PF decreases the likelihood of being listed for KT and increases the risk of adverse post-KT outcomes. Recent trials suggest that exercise is a promising strategy to improve PF among KT candidates and recipients.

Summary

PF is a potentially modifiable risk factor for adverse pre- and post-KT outcomes. Research is needed to determine the ideal PF metric for use in KT evaluations and interventions to improve PF.

Role of novel biomarkers in kidney transplantation

Clinical application of biomarkers is an integral component of transplant care. Clinicians and scientists alike are in search of better biomarkers than the current serologic (serum creatinine, donor-specific antibodies), urine-derived (urinalysis, urine protein), and histologic ones we now use. The science behind recent biomarker discovery spans across multiple molecular biologic disciplines, including transcriptomics, proteomics, and metabolomics. Innovative methodology and integration of basic and clinical approaches have allowed researchers to unearth molecular phenomena preceding clinical disease. Biomarkers can be classified in several ways. In this review, we have classified them via their origin and outcome: Primarily immunologic, i.e., representative of immune regulation and dysfunction and non-immunologic, pertaining to delayed graft function, cardiovascular events/mortality, infection, malignancy, post-transplant diabetes, graft, and patient survival. Novel biomarker uses to guide the diagnosis and management of transplant-related outcomes is a promising area of research. However, the use of biomarkers to predict outcomes after kidney transplantation is not well studied. In this review, we summarize the recent studies illustrating biomarker use and transplant outcomes.

Exploring the impact of the COVID-19 pandemic and UK lockdown on individuals with experience of eating disorders

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic may raise unique challenges for individuals with experience of eating disorders. Many factors have potential for detrimental impacts on psychological wellbeing and eating disorder recovery, including: Disruption to living situations, 'social distancing' restrictions, difficult access to healthcare, and societal changes to food behaviours and technology usage. To date, little is known on the impact of the pandemic on this population, particularly within the UK.

METHOD

A mixed-methods online survey was developed for the purpose of this study. Data was collected from 129 individuals currently experiencing, or in recovery from, an eating disorder during the early stages of the UK pandemic lockdown. Participants were aged between 16 and 65 years, with 121 participants identifying as female, 7 male and 1 participant preferring not to disclose their gender.

RESULTS

Findings suggest that the pandemic is having a profound, negative impact upon individuals with experience of eating disorders. Eight key themes were generated: Disruption to living situation, increased social isolation and reduced access to usual support networks, changes to physical activity rates, reduced access to healthcare services, disruption to routine and perceived control, changes to relationship with food, increased exposure to triggering messages, and positive outcomes. The results suggest detrimental impacts on psychological wellbeing including decreased feelings of control, increased feelings of social isolation, increased rumination about disordered eating, and low feelings of social support.

CONCLUSIONS

Individuals with eating disorders are at significant risk of negative impacts of the pandemic. There is a vital need for interventions to support this population. Inequalities in healthcare provision were identified, emphasising a need for a more cohesive approach to remote treatment across UK healthcare services. Positive aspects of technology use were identified but the results suggest a need to address and/or limit the potential for negative impacts of public messages around food and exercise behaviours, and to co-design technologies with end-users to facilitate effective treatment.

How is the minimal clinically important difference established in health-related quality of life instruments? Review of anchors and methods

Background

The aim of this systematic review is to describe the different types of anchors and statistical methods used in estimating the Minimal Clinically Important Difference (MCID) for Health-Related Quality of Life (HRQoL) instruments.

Methods

PubMed and Google scholar were searched for English and French language studies published from 2010 to 2018 using selected keywords. We included original articles (reviews, meta-analysis, commentaries and research letters were not considered) that described anchors and statistical methods used to estimate the MCID in HRQoL instruments.

Results

Forty-seven papers satisfied the inclusion criteria. The MCID was estimated for 6 generic and 18 disease-specific instruments. Most studies in our review used anchor-based methods (n = 41), either alone or in combination with distribution-based methods. The most common applied anchors were non-clinical, from the viewpoint of patients. Different statistical methods for anchor-based methods were applied and the Change Difference (CD) was the most used one. Most distributional methods included 0.2 standard deviations (SD), 0.3 SD, 0.5 SD and 1 standard error of measurement (SEM). MCID values were very variable depending on methods applied, and also on clinical context of the study.

Conclusion

Multiple anchors and methods were applied in the included studies, which lead to different estimations of MCID. Using several methods enables to assess the robustness of the results. This corresponds to a sensitivity analysis of the methods. Close collaboration between statisticians and clinicians is recommended to integrate an agreement regarding the appropriate method to determine MCID for a specific context.

Screening Performance of Edmonton Symptom Assessment System in Kidney Transplant Recipients

An average prevalence of 35% for psychiatric comorbidity has been reported in kidney transplant recipients (KTRs) and an even higher prevalence of other psychosocial syndromes, as defined by the Diagnostic Criteria for Psychosomatic Research (DCPR), has also been found in this population. Consequently, an easy, simple, rapid psychiatric tool is needed to measure physical and psychological symptoms of distress in KTRs. Recently, the Edmonton Symptom Assessment System (ESAS), a pragmatic patient-centred symptom assessment tool, was validated in a single cohort of KTRs. The aims of this study were: to test the screening performances of ESAS for the International Classification of Diseases-10th Revision (ICD-10) psychiatric diagnoses in KTRs; to investigate the optimal cut-off points for ESAS physical, psychological and global subscales in detecting ICD-10 psychiatric diagnoses; and to compare ESAS scores among KTR with ICD-10 diagnosis and DCPR diagnosis. 134 KTRs were evaluated and administered the MINI International Neuropsychiatric Interview 6.0 and the DCPR Interview. The ESAS and Canadian Problem Checklist (CPC) were given as self-report instruments to be filled in and were used to examine the severity of physical and psychological symptoms and daily-life problems. The physical distress sub-score (ESAS-PHYS), psychological distress sub-score (ESAS-PSY) and global distress score (ESAS-TOT) were obtained by summing up scores of six physical symptoms, four psychological symptoms and all single ESAS symptoms, respectively. Routine biochemistry, immunosuppressive agents, socio-demographic and clinical data were collected. Receiving Operating Characteristic (ROC) analysis was used to examine the ability of the ESAS emotional distress (DT) item, ESAS-TOT, ESAS-PSY and ESAS-PHYS, to detect psychiatric cases defined by using MINI6.0. The area under the ROC curve for ESAS-TOT, ESAS-PHYS, ESAS-PSY and DT item were 0.85, 0.73, 0.89, and 0.77, respectively. The DT item, ESAS-TOT and ESAS-PSY optimal cut-off points were ≥4 (sensitivity 0.74, specificity 0.73), ≥20 (sensitivity 0.85, specificity 0.74) and ≥12 (sensitivity 0.85, specificity 0.80), respectively. No valid ESAS-PHYS cut-off was found (sensitivity <0.7, specificity <0.7). Thirty-nine (84.8%) KTRs with ICD-10 diagnosis did exceed both ESAS-TOT and ESAS-PSY cut-offs. Higher scores on the ESAS symptoms (except shortness of breath and lack of appetite) and on the CPC problems were found for ICD-10 cases and DCRP cases than for ICD-10 no-cases and DCPR no-cases. This study shows that ESAS had an optimal screening performance (84.8%) to identify ICD-10 psychiatric diagnosis, evaluated with MINI; furthermore, ESAS-TOT and ESAS-PSY cut-off points could provide a guide for clinical symptom management in KTRs.

Employment Status and Associations with Workability, Quality of Life and Mental Health after Kidney Transplantation in Austria

Kidney transplantation (KTx) in end-stage renal disease is associated with a significant increase in quality of life (QoL) and self-perceived health, optimally leading to the maintenance of employment or return to work (RTW) in working-age patients. The aim of this study was to assess individual factors including the QoL and mental health of kidney transplant recipients (KTRs) associated with employment after transplantation. A cross-sectional study including working-age patients with a history of KTx after 2012 was conducted at two Austrian study centers (Vienna and Graz). Brief Symptom Inventory (BSI-18), World Health Organization Quality of Life (WHOQOL-Bref) and Workability Index (WAI) were assessed along with detailed questionnaires on employment status. Out of n = 139 KTRs (43.2 ± 9.07 years; 57.6% male), 72 (51.8%) were employed. Employed patients were more frequently in a partnership (p = 0.018) and had higher education levels (p = 0.01) and QoL scores (<0.001). Unemployed KTRs reported fatigue and mental health issues more often (p < 0.001), and had significantly higher anxiety, depression and somatization scores (BSI-18). In unadjusted logistical regression, workability score (WAS; odds ratio (OR) = 3.39; 95% confidence interval (CI) = 1.97–5.82; p < 0.001), partnership (OR = 5.47; 95% CI 1.43–20.91; p = 0.013) and no psychological counseling after KTx (OR = 0.06; 95% CI = 0.003–0.969; p = 0.048) were independently associated with employment. Self-assessed mental health, workability and QoL were significantly associated with employment status after KTx. Thus, in order to facilitate RTW after KTx in Austria, vocational rehabilitation and RTW programs addressing KTRs should focus on increasing social support and care for their mental health.

Development and validation of the Kidney Transplantation and Quality of Life, a Korean questionnaire to assess the general quality of life and other health issues associated with medication change in kidney transplant recipients

Background

This study aimed to develop and validate the Kidney Transplantation and Quality of Life (KTQoL) questionnaire to evaluate the quality of life (QoL) in Korean kidney transplantation (KT) patients. During the validation, the KTQoL was used to compare the QoL of KT patients before and after conversion from twice-daily to a once-daily regimen of tacrolimus.

Methods

Construct and content validity of the 24-item KTQoL was evaluated using factor analysis and a panel of experts, respectively. The questionnaire was validated in 50 KT patients, conducted before and after conversion from twice-daily to once-daily tacrolimus. Internal consistency was evaluated based on Cronbach’s alpha coefficient.

Results

The KTQoL showed high internal consistency (Cronbach’s alpha 0.71 to 0.88). Besides the Concerns category, both the general and specific QoL of KT patients were relatively good (≥70% of positive responses) and did not change markedly after conversion to the once-daily regimen (42.9±8.8 vs. 43.6±8.6, P=0.740). After conversion, men scored better than women in total KTQoL, Specific QoL, and Symptoms, while employed patients had better Daily Life scores and showed greater improvement in Daily Life scores compared with unemployed patients.

Conclusions

The KTQoL seems to be a reliable instrument to evaluate general and specific QoL in Korean KT patients. Most patients evaluated their QoL positively. Conversion to once-daily tacrolimus had no significant effect on QoL in the total sample of KT patients. The QoL of men and/or employed persons might improve more after conversion to once-daily tacrolimus.

The Symptoms and Impact of Recurrent Focal Segmental Glomerulosclerosis in Kidney Transplant Recipients: A Conceptual Model of the Patient Experience

Introduction

We qualitatively examined the symptoms and impact of recurrent primary focal segmental glomerulosclerosis (rpFSGS) in kidney transplant recipients, compared with two related FSGS populations, to characterize the experience of patients with rpFSGS.

Methods

A literature review identified 58 articles concerning the experience of patients with pFSGS and/or rpFSGS in three groups: pre-transplant pFSGS, post-transplant rpFSGS, or post-transplant non-recurrent pFSGS. Literature findings were used to construct a preliminary conceptual model incorporating the symptoms and impact of rpFSGS, which was refined on the basis of qualitative interviews with clinicians. Twenty-five patients (rpFSGS: n = 15; pre-transplant pFSGS: n = 5; post-transplant non-recurrent pFSGS: n = 5) were interviewed to characterize the experience of patients with rpFSGS and compare it with other FSGS populations, and findings were used to finalize the conceptual model.

Results

The impact of pFSGS/rpFSGS described in the literature was diverse. Treatment-related symptoms, along with anxiety and depression, were considered important features of rpFSGS in addition to the findings from the literature review, according to clinicians. Patient-reported tiredness and swelling were the most common/disturbing symptoms associated with rpFSGS, while physical activity restrictions and adverse effects on work/social life were considered the most profound impact concepts. The collective disease experience was different for patients with rpFSGS and non-recurrent pFSGS, although psychological impact, including treatment-related anxiety and depression, were common to both groups.

Conclusions

Post-transplant recipients with rpFSGS display a greater symptom burden and experience a more diverse impact than those with non-recurrent pFSGS, highlighting the importance of effective patient monitoring and introducing effective treatments for the prevention and management of pFSGS recurrence.

Funding

Astellas Pharma Global Development, Inc.

Electronic Supplementary Material

The online version of this article (10.1007/s12325-019-01110-5) contains supplementary material, which is available to authorized users.

Histopathological characteristics and causes of kidney graft failure in the current era of immunosuppression

BACKGROUND

The histopathological findings on the failing kidney allograft in the modern era is not well studied. In this study, we present our experience working with kidney transplant recipients with graft failure within one year of the biopsy.

AIM

To report the histopathological characteristics of failed kidney allografts in the current era of immunosuppression based on the time after transplant, cause of the end-stage renal disease and induction immunosuppressive medications.

METHODS

In a single-center observational study, we characterized the histopathological findings of allograft biopsies in kidney transplant recipients with graft failure within one year after the biopsy.

RESULTS

We identified 329 patients with graft failure that met the selection criteria between January 1, 2006 and December 31, 2016. The three most common biopsy findings were interstitial fibrosis and tubular atrophy (IFTA, 53%), acute rejection (AR, 43%) and transplant glomerulopathy (TG, 33%). Similarly, the three most common causes of graft failure based on the primary diagnosis were AR (40%), TG (17%), and IFTA (13%). Most grafts failed within two years of post-transplant (36%). Subsequently, approximately 10%-15% of grafts failed every two years: > 2-4 years (16%), > 4-6 years (13%), > 6-8 years (11%), > 8-10 years (9%) and > 10 years (16%). AR was the most common cause of graft failure in the first six years (48%), whereas TG was the most prevalent cause of graft failure after 6 years (32%) of transplant.

CONCLUSION

In the current era of immunosuppression, AR is still the most common cause of early graft failure, while TG is the most prevalent cause of late graft failure.

K121Q polymorphism in the Ectonucleotide Pyrophosphatase/Phosphodiesterase 1 gene is associated with acute kidney rejection

The identification of risk factors for acute rejection (AR) may lead to strategies to improve success of kidney transplantation. Ectonucleotidases are ectoenzymes that hydrolyze extracellular nucleotides into nucleosides, modulating the purinergic signaling. Some members of the Ectonucleotidase family have been linked to transplant rejection processes. However, the association of Ectonucleotide Pyrophosphatase / Phosphodiesterase 1 (ENPP1) with AR has not yet been evaluated. The aim of this study was to evaluate the association between the K121Q polymorphism of ENPP1 gene and AR in kidney transplant patients. We analyzed 449 subjects without AR and 98 with AR from a retrospective cohort of kidney transplant patients from Southern Brazil. K121Q polymorphism was genotyped using allelic discrimination-real-time PCR. Cox regression analysis was used to evaluate freedom of AR in kidney transplant patients according to genotypes. Q allele frequency was 17.6% in recipients without AR and 21.9% in those with AR (P = 0.209). Genotype frequencies of the K121Q polymorphism were in Hardy-Weinberg equilibrium in non-AR patients (P = 0.70). The Q/Q genotype (recessive model) was associated with AR (HR = 2.83, 95% CI 1.08–7.45; P = 0.034) after adjusting for confounders factors. Our findings suggest a novel association between the ENPP1 121Q/Q genotype and AR in kidney transplant recipients.

Does Kidney Transplantation Affect Sleep and Fatigue in Patients With Kidney Disease?

Supplemental Digital Content is available in the text.

Sleep disorders and fatigue are highly prevalent in chronic kidney disease (CKD) and end-stage kidney disease (ESKD) patients but there is limited evidence on the effect of kidney transplant (KTx) on these.

Tuberculosis in renal transplant recipients: Our decade long experience with an opportunistic invader

AIM

To study the incidence, pattern of tuberculosis, Its risk factors, and prognosis in renal transplantation recipients in Indian population.

SETTINGS AND DESIGN

This study retrospectively analyzed the patients who underwent renal transplantation at Ramaiah medical college Hospitals, India from 2004 to 2015.

METHODS AND MATERIAL

The study enrolled 244 patients. Diagnosis was based on radio0imaging, sputum smear, culture and polymerase chainreaction and histology.

STATISTICAL ANALYSIS USED

A descriptive univariate analysis was performed to identify the individual risk factors.

RESULTS

The TB infection was present in 21/244 (8.6%) renal transplantation patients (mean age ± SD = 44.3 ± 12.9 years). Pulmonary tuberculosis was the commonest (57%) followed by extrapulmonary tuberculosis (43%). Type II diabetes mellitus (DM) (14.6%; p = 0.0169)was significant risk factor. Majority of the patients (n = 18, 10.7%) were on standard tripledrug immunosuppression. The median duration of anti0tubercular therapy was 14 months and crude mortality was 19%.

CONCLUSIONS

High index of suspicion for tuberculosis is require d in renal transplant recipients owing to their immunocompromised status and atypical presentations. Higher age, DM and use of immunosuppressants increase the risk for post0renal transplantation tuberculosis. Interactions between anti0tubercular drugs and immunosuppressants need to be considered in these patients.

Adverse effects of mycophenolic acid in renal transplant recipients: gender differences

Background Mycophenolic acid is widely used immunosuppressive drug, associated with adverse effects which increase patient morbidity and decrease medication adherence. Objective To evaluate the adverse effects in renal transplant recipients under mycophenolate treatment with respect to gender. Setting University Clinical Centre of Nis, Clinic of Nephrology, Serbia. Method This research included 96 renal transplant recipients, who received immunosuppressive regimen, based on tacrolimus or cyclosporin A, prednisone and mycophenolic acid. The high-performance liquid chromatography method combined with protein precipitation was used for the analysis of mycophelate concentration in human plasma. Drug concentration and dose-adjusted concentration were determined with respect to the patients' gender. An adverse effect scoring system developed by nephrologists within the University of Buffalo Nephrology/Transplant Program was used to monitor adverse effects of therapy. Main outcome measure Individual and scores of adverse effects in relation to the dosing regimen and gender. Results Results showed statistically lower dose and concentrations in men compared to the women in our investigation group. Also, female patients demonstrated higher mean scores (cumulative and subscores) within the same dosing regimens of mycophenolic acid. The gastrointestinal score was significantly higher in women who received a dose greater than 720 mg compared to men (0.20 ± 0.12 vs 0.12 ± 0.12). Women demonstrated higher individual adverse effects such as diarrhea and skin changes (41.7 vs 17.0; p = 0.038 and 62.5 vs 30.2; p = 0.037, respectively). Conclusions The results of our research showed that recipients' gender may play an important role in pharmacokinetic profile of mycophenolic acid, suggesting that women had higher concentration of mycophenolic acid and more serious side effects.

Strategies for incorporating patient-reported outcomes in the care of people with chronic kidney disease (PRO kidney): a protocol for a realist synthesis

BACKGROUND

Patient-reported outcomes and experience measures (jointly referred to here as PROs) are internationally recognized as a means for patients to provide information about their quality of life, symptoms, and experiences with care. Although increasingly recognized as key to improving the quality of healthcare at individual (e.g., patients, caregivers, and providers) and aggregate (e.g., government, policy/system-wide decision-making) levels, there are important knowledge gaps in our understanding of how PROs are, and can be, used across different settings, particularly in nephrology to enhance person-centered care. This knowledge is needed for developing strategies to guide optimal use of PROs in nephrology care. Currently, no strategies exist. The purpose of this review is to address this knowledge gap by answering the following realist question: How can PROs be used to enhance person-centered nephrology care, both at individual and aggregate levels?

METHODOLOGY

Realist synthesis is an explanatory approach to data synthesis that aims to explain how context and mechanisms influence the outcome of an intervention. An initial program theory will be developed through the systematic search of the published literature in bibliographic databases (Ovid MEDLINE, Ovid Embase, EBSCOhost CINAHL, Web of Science, and Scopus) on existing theories explaining how PROs are used in healthcare settings. This initial program theory will then be tested and refined through the process of realist synthesis, using context-mechanism-outcome configurations. A kidney-specific program theory will then be created to address the utilization of PROs in nephrology across individual and aggregate levels to augment person-centered care. Searching will be iterative and refined as data is extracted and analyzed using a pilot-tested context + mechanism = outcome heuristic. Throughout, we will consult methodological experts, research team practitioners, and the Patient Advisory Committee to help refine the theories. Last, we will develop and disseminate knowledge translation products widely to knowledge user groups.

DISCUSSION

The utilization of PROs remains a challenge in nephrology. The findings from this synthesis will provide a framework to guide both policy makers and practitioners on how to enhance person-centered care through successful utilization of PROs across individual and aggregate levels in nephrology.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017056063.

Characteristics and Outcomes of Kidney Transplant Recipients with a Functioning Graft for More than 25 Years

Background

Information regarding the clinical characteristics and outcomes of kidney transplant recipients (KTRs) with > 25 years of graft survival is limited.

Methods

In this single-center observational study, we characterized KTRs transplanted between 1973 and 1992 with active follow-up as of July 31, 2017.

Results

We identified 112 patients with > 25 years of allograft function. The mean posttransplantation follow-up was 29.8 ± 4.0 years. Glomerulonephritis was the most common cause of end-stage renal disease (ESRD) (52%). The majority received live donor transplants (66%), including 25 patients (22%) with human leukocyte antigen-matched kidneys. The incidence of biopsy-confirmed acute rejection was 21%, ranging from 0 to 26 years post transplantation. Donor-specific antibodies (DSA) were checked in 80% of patients at a mean of 28.4 ± 0.11 years post transplantation. Of these, only 15% were positive. The incidence of malignancy was 44%, with nonmelanoma skin cancers being most common. The incidence of infectious complications was 77%, mostly represented by urinary tract infections. At the time of last follow-up, 63% were on a calcineurin inhibitor (CNI)-free regimen, mean serum creatinine was 1.4 ± 0.6 mg/dL, and the prevalence of hypertension and dyslipidemia was 89 and 88%, respectively.

Conclusion

The majority of patients with a long-term functioning graft had glomerulonephritis as cause of ESRD, had received a live donor kidney, were on a CNI-free regimen, and had a low incidence of DSA and opportunistic infections. These characteristics define a unique group of patients requiring specific posttransplantation monitoring and management.

Comparative Study on Variation of Quality of Life of Patients of Preemptive Kidney Transplantation and Nonpreemptive Kidney Transplantation

BACKGROUND

There have been few studies that have reported the influence of kidney transplantation on the quality of life (QOL) of patients of preemptive kidney transplantation (PKT) and nonpreemptive kidney transplantation (NPKT).

MATERIAL AND METHODS

Fifty patients of PKT and 49 patients of NPKT were employed as study subjects. A questionnaire survey using Short Form 36 and Kidney Disease QOL on patients' physical and psychological QOL was performed for these patients prior to transplantation and 1 month, 3 months, and 1 year after transplantation.

RESULTS

The analysis of results has revealed that transplantation clearly has improved the physical and psychological QOL in patients with end-stage renal disease. For the items regarding physical burdens incurred by the transplantation, patient QOL deteriorated on a single occasion 1 month after the transplantation while it was improved 1 year after the transplantation. For the items regarding psychological burdens, the mental condition of the patients was improved overall without deterioration over time. Concerning the "Effect of Kidney Disease" and "Burden of Kidney Disease," QOL was significantly better in PKT than NPKT at baseline before transplantation, although the significant difference gradually decreased 1 month and 3 months after the transplantation and disappeared after 1 year.

CONCLUSION

Transplantation certainly improved the QOL of patients with end-stage renal disease. Before transplantation, PKT was clearly better than NPKT in the QOL items associated with "Burden of Kidney Disease." This indicated that patients of PKT have improved QOL compared to patients of NPKT, and that the overall awareness of kidney disease is decreased. A postoperative gap in mental and bodies was observed especially in PKT, however, could be overcome by nursing interventions.

Factors associated with Health-Related Quality of Life in Kidney Transplant Recipients in France

Background

Health-Related Quality of Life (HRQoL) assessment after kidney transplantation has become an important tool in evaluating outcomes. This study aims to identify the associated factors with HRQoL among a representative sample size of Kidney Transplant Recipients (KTR) at the time of their inclusion in the study.

Methods

Data of this cross-sectional design is retrieved from a longitudinal study conducted in five French kidney transplant centers in 2011, and included KTR aged 18 years with a functioning graft for at least 1 year. Measures include demographic, psycho-social and clinical characteristics. To evaluate HRQoL, the Short Form-36 Health Survey (SF-36) and a HRQoL instrument for KTR (ReTransQol) were administered. Multivariate linear regression models were performed.

Results

A total of 1424 patients were included, with 61.4% males, and a mean age of 55.7 years (±13.1). Demographic and clinical characteristics were associated with low HRQoL scores for both questionnaires. New variables were found in our study: perceived poor social support and being treated by antidepressants were associated with low scores of Quality of Life (QoL), while internet access was associated with high QoL scores.

Conclusion

The originality of our study’s findings was that psycho-social variables, particularly KTR treated by antidepressants and having felt unmet needs for any social support, have a negative effect on their QoL. It may be useful to organize a psychological support specifically adapted for patients after kidney transplantation.

Case Report: Spontaneous Hemorrhage of a Rare Renal Tumor in the Native Kidney of a Renal Transplant Recipient

Renal cancers are some of the most common solid organ malignancies found during follow-up of patients who have undergone renal transplantation (RT). In this case report, we describe a life-threatening spontaneous hemorrhage of a rare subtype of renal cell carcinoma in the native kidney of a 27-year-old man, 4 years after RT. After fluid resuscitation and stabilization, the patient underwent emergent open radical nephrectomy with the final histopathology reporting T1bN0Mx mucinous tubular and spindle cell (MTSC) carcinoma. This case report highlights the need to consider an underlying malignancy in patients who presents with spontaneous hemorrhage of native kidneys after RT.

Psychosocial Variables Associated with Immunosuppressive Medication Non-Adherence after Renal Transplantation

INTRODUCTION

Non-adherence to immunosuppressive medication is regarded as an important factor for graft rejection and loss after successful renal transplantation. Yet, results on prevalence and relationship with psychosocial parameters are heterogeneous. The main aim of this study was to investigate the association of immunosuppressive medication non-adherence and psychosocial factors.

METHODS

In 330 adult renal transplant recipients (≥12 months posttransplantation), health-related quality of life, depression, anxiety, social support, and subjective medication experiences were assessed, and their associations with patient-reported non-adherence was evaluated.

RESULTS

33.6% of the patients admitted to be partially non-adherent. Non-adherence was associated with younger age, poorer social support, lower mental, but higher physical health-related quality of life. There was no association with depression and anxiety. However, high proportions of clinically relevant depression and anxiety symptoms were apparent in both adherent and non-adherent patients.

CONCLUSION

In the posttransplant follow-up, kidney recipients with lower perceived social support, lower mental and higher physical health-related quality of life, and younger age can be regarded as a risk group for immunosuppressive medication non-adherence. In follow-up contacts with kidney transplant patients, physicians may pay attention to these factors. Furthermore, psychosocial interventions to optimize immunosuppressive medication adherence can be designed on the basis of this information, especially including subjectively perceived physical health-related quality of life and fostering social support seems to be of importance.

Sex and gender disparities in the epidemiology and outcomes of chronic kidney disease

Improved understanding of sex and gender-specific differences in the aetiology, mechanisms and epidemiology of chronic kidney disease (CKD) could help nephrologists better address the needs of their patients. Population-based studies indicate that CKD epidemiology differs by sex, affecting more women than men, especially with regard to stage G3 CKD. The effects of longer life expectancy on the natural decline of glomerular filtration rate (GFR) with age, as well as potential overdiagnosis of CKD through the inappropriate use of GFR equations, might be in part responsible for the greater prevalence of CKD in women. Somewhat paradoxically, there seems to be a preponderance of men among patients starting renal replacement therapy (RRT); the protective effects of oestrogens in women and/or the damaging effects of testosterone, together with unhealthier lifestyles, might cause kidney function to decline faster in men than in women. Additionally, elderly women seem to be more inclined to choose conservative care instead of RRT. Dissimilarities between the sexes are also apparent in the outcomes of CKD. In patients with predialysis CKD, mortality is higher in men than women; however, this difference disappears for patients on RRT. Although access to living donor kidneys among men and women seems equal, women have reduced access to deceased donor transplantation. Lastly, health-related quality of life while on RRT is poorer in women than men, and women report a higher burden of symptoms. These findings provide insights into differences in the underlying pathophysiology of disease as well as societal factors that can be addressed to reduce disparities in access to care and outcomes for patients with CKD.

Sex and gender disparities in the epidemiology and outcomes of chronic kidney disease

Improved understanding of sex and gender-specific differences in the aetiology, mechanisms and epidemiology of chronic kidney disease (CKD) could help nephrologists better address the needs of their patients. Population-based studies indicate that CKD epidemiology differs by sex, affecting more women than men, especially with regard to stage G3 CKD. The effects of longer life expectancy on the natural decline of glomerular filtration rate (GFR) with age, as well as potential overdiagnosis of CKD through the inappropriate use of GFR equations, might be in part responsible for the greater prevalence of CKD in women. Somewhat paradoxically, there seems to be a preponderance of men among patients starting renal replacement therapy (RRT); the protective effects of oestrogens in women and/or the damaging effects of testosterone, together with unhealthier lifestyles, might cause kidney function to decline faster in men than in women. Additionally, elderly women seem to be more inclined to choose conservative care instead of RRT. Dissimilarities between the sexes are also apparent in the outcomes of CKD. In patients with predialysis CKD, mortality is higher in men than women; however, this difference disappears for patients on RRT. Although access to living donor kidneys among men and women seems equal, women have reduced access to deceased donor transplantation. Lastly, health-related quality of life while on RRT is poorer in women than men, and women report a higher burden of symptoms. These findings provide insights into differences in the underlying pathophysiology of disease as well as societal factors that can be addressed to reduce disparities in access to care and outcomes for patients with CKD.

Long-Term Outcomes of Kidney Transplantation From Expanded-Criteria Deceased Donors: A Single-Center Experience

BACKGROUND

Organ shortage has prompted the use of expanded-criteria donors (ECDs). Our objective was to compare long-term outcomes of kidney transplants from ECDs with those from concurrent standard-criteria donors (SCDs). In addition, we evaluated variables associated with graft survival in both groups.

METHODS

We retrospectively reviewed all 617 deceased-donor kidney transplantations performed from 2005 to 2009 in our department. The population was divided according to donor status into ECD or SCD. Patients were followed until 5 years after transplantation, death, graft failure, or loss to follow-up.

RESULTS

We transplanted 150 deceased-donor kidneys from ECDs and 467 from SCDs. ECD were older, more frequently women, had a lower pre-retrieval glomerular filtration rate, and more frequently died due to cerebrovascular accident. ECD recipients were older, presented a lower proportion of black race, more frequently were on hemodialysis, and presented a higher rate of first kidney transplants. Mean glomerular filtration rate was consistently lower in the ECD group. Patient and graft survivals were lower in the ECD group, but statistical significance was present only in graft survival censored for death with a functioning graft at 3 years and graft survival noncensored for death with a functioning graft at 5 years. Younger recipient ages, longer time on dialysis, acute rejection episodes, and glomerular filtration rate at 1 year after transplantation were independent risk factors for lower graft survival.

CONCLUSIONS

Transplantation with the use of ECD kidneys provide quite satisfactory patient and graft survival rates despite their poorer long-term outcomes.

Posttransplant Outcomes of Kidneys Donated After Brain Death Followed by Circulatory Death: A Cohort Study of 128 Chinese Patients

Background

Donation after brain death followed by circulatory death (DBCD) is a new class in the unique Chinese donor classification system. Currently, in China, the organ transplantation of DBCD is rising. However, there is a dearth of research on the characteristics and outcomes of DBCD kidney transplantation.

Method

We collected 128 DBCD renal transplant patients who underwent surgery between June 2013 and May 2016 at our center to analyze clinical outcomes and to share our experience to enhance perioperative management in DBCD kidney transplantation.

Results

At the end of follow-up, no patients experienced primary nonfunction, but delayed graft function occurred in 25.8%. One- and 3-year graft survivals were 97.7% and 94.5%, respectively. The average length of stay was 20.88 ± 14.6 days, the incidence of posttransplant complications was 46.1% (59 patients), and 31 patients suffered more than 1 complication. In addition, the average length of stay of patients without complications and with at least 1 complication was 13.07 ± 2.01 days and 30.02 ± 17.4 days, respectively. There was a significantly higher incidence of complications associated with the postoperative hospital stay in DBCD patients.

Conclusions

Patients who received a DBCD kidney demonstrated a good outcome in terms of both graft survival and graft function. Hence, DBCD is suitable for national reality and conditions and offers a feasible option for deceased-donor kidney transplantation in China. To prevent complications and reduce the duration of hospital stay, we should strengthen preoperative and postoperative management.

Plasma Neutrophil Gelatinase-Associated Lipocalin as a Marker for Prediction of 3-Month Graft Survival after Kidney Transplantation

BACKGROUND

Ischemic injury during organ transplantation increases the risk of acute and chronic rejections by promoting alloimmune responses. Measurement of neutrophil gelatinase-associated lipocalin (NGAL) immediately after kidney transplantation may be promising for early detection of ischemic injuries to allograft.

OBJECTIVE

This study assessed possible predictive values of plasma NGAL levels during first hours after kidney transplantation for graft loss within the first 3 months after transplantation.

METHODS

45 kidney transplant recipients were classified into those without graft loss or with graft loss during 3 months after transplantation. Plasma NGAL levels were measured before and at 2, 6, 12, 24 and 96 hours after transplantation. Serum creatinine concentration was assessed daily during hospitalization and at 1, 2, and 3 months post-transplantation.

RESULTS

Serum creatinine and plasma NGAL levels were consistently higher in patients with graft loss compared with those without graft loss. At 2, 24, and 96 hours after transplantation, plasma NGAL concentration was significantly higher in patients who developed allograft loss within 3 months post-transplantation. The cutoff point of plasma NGAL at 2, 24, and 96 hours after transplantation for prediction of graft loss was 304.5 ng/mL (sensitivity of 71.4%, and specificity of 73.7%), 207.8 ng/mL(sensitivity of 85.7%, and specificity of 60.5%), and 184 ng/mL (sensitivity of 85.7%, and specificity of 71.1%), respectively.

CONCLUSION

Plasma NGAL levels at 2, 24, and 96 hours after transplantation can predict 3-month graft loss with fair sensitivity and specificity.

The Novel Application of Genomic Profiling Assays to Shorten Inactive Status for Potential Kidney Transplant Recipients With Breast Cancer

The concern about cancer recurrence has traditionally resulted in delaying kidney transplantation for 2-5 years after a cancer diagnosis in patients who are otherwise eligible for transplant. This period of inactive status to observe the tumor biology can result in significant morbidity and decreased quality of life for patients with end-stage renal disease (ESRD). We reported the novel application of genomic profiling assays in breast cancer to identify low-risk cancers in two patients with ESRD who were able to have the mandatory inactive status eliminated prior to kidney transplantation.

Referral for Kidney Transplantation and Indicators of Quality of Dialysis Care: A Cross-sectional Study

BACKGROUND

Dialysis facility performance measures to improve access to kidney transplantation are being considered. Referral of patients for kidney transplantation evaluation by the dialysis facility is one potential indicator, but limited data exist to evaluate whether referral is associated with existing dialysis facility quality indicators.

STUDY DESIGN

Cross-sectional study.

SETTING & PARTICIPANTS

12,926 incident (July 2005 to September 2011) adult (aged 18-69 years) patients treated at 241 dialysis facilities with complete quality indicator information from US national registry data linked to transplantation referral data from all 3 Georgia kidney transplantation centers.

FACTORS

Facility performance on dialysis quality indicators (high, intermediate, and low tertiles).

OUTCOME

Percentages of patients referred within 1 year of dialysis therapy initiation at dialysis facility.

RESULTS

Overall, a median of 25.4% of patients were referred for kidney transplantation within 1 year of dialysis therapy initiation. Higher facility-level referral was associated with better performance with respect to standardized transplantation ratio (high, 28.6%; intermediate, 25.1%; and low, 22.9%; P=0.001) and percentage waitlisted (high, 30.7%; intermediate, 26.8%; and low, 19.2%; P<0.001). Facility-level referral was not associated with indicators of quality of care associated with dialysis therapy initiation, including percentage of incident patients being informed of transplantation options. For most non-transplantation-related indicators of high-quality care, including those capturing mortality, morbidity, and anemia management, better performance was not associated with higher facility-level transplantation referral.

LIMITATIONS

Potential ecologic fallacy and residual confounding.

CONCLUSIONS

Transplantation referral among patients at dialysis facilities does not appear to be associated with overall quality of dialysis care at the facility. Quality indicators related to kidney transplantation were positively associated with, but not entirely correspondent with, higher percentages of patients referred for kidney transplantation evaluation from dialysis facilities. These results suggest that facility-level referral, which is within the control of the dialysis facility, may provide information about the quality of dialysis care beyond current indicators.

Quality of Life After Kidney Transplantation: A Prospective Study

BACKGROUND

The purpose of renal transplantation is to achieve a maximal improvement in quality of life (QoL) and life expectancy in patients with end-stage renal disease (ESRD) while minimizing the potential side effects of this procedure. It is important to achieve an optimal balance between graft function and the patient's QoL. This study was designed to assess the changes in the QoL after kidney transplantation (KTx) in patients with ESRD previously treated with hemodialysis (HD) or peritoneal dialysis (PD).

METHODS

QoL was prospectively analyzed in 69 patients after kidney transplantation in a single-center study. Patients with ESRD were divided into 2 groups: those previously treated with HD (n = 44 patients; group 1) or PD (n = 25 patients; group 2). Both groups were asked to complete the KDQOL-SFtm questionnaire before and 12 months after kidney transplantation.

RESULTS

We observed significant differences in many parameters of QoL in both groups after KTx but more positive changes of most parameters in question exhibited by patients previously treated by means of HD than PD. Patients treated with HD and PD demonstrated improvement after KTx in 74% of dimensions. There were no statistical differences in the QoL between group 1 and group 2 before or after KTx.

CONCLUSIONS

The study demonstrated post- to pre-transplant improvements of QoL independently of previous treatment.

A diverse virome in kidney transplant patients contains multiple viral subtypes with distinct polymorphisms

Recent studies have established that the human urine contains a complex microbiome, including a virome about which little is known. Following immunosuppression in kidney transplant patients, BK polyomavirus (BKV) has been shown to induce nephropathy (BKVN), decreasing graft survival. In this study we investigated the urine virome profile of BKV+ and BKV- kidney transplant recipients. Virus-like particles were stained to confirm the presence of VLP in the urine samples. Metagenomic DNA was purified, and the virome profile was analyzed using metagenomic shotgun sequencing. While the BK virus was predominant in the BKV+ group, it was also found in the BKV- group patients. Additional viruses were also detected in all patients, notably including JC virus (JCV) and Torque teno virus (TTV) and interestingly, we detected multiple subtypes of the BKV, JCV and TTV. Analysis of the BKV subtypes showed that nucleotide polymorphisms were detected in the VP1, VP2 and Large T Antigen proteins, suggesting potential functional effects for enhanced pathogenicity. Our results demonstrate a complex urinary virome in kidney transplant patients with multiple viruses with several distinct subtypes warranting further analysis of virus subtypes in immunosuppressed hosts.

Is Kidney Transplantation a Better State of CKD? Impact on Diagnosis and Management

Patients with CKD are at increased risk for cardiovascular events, hospitalizations, and mortality. Kidney transplantation (KTx) is the preferred treatment for end-stage kidney disease. Although comorbidities including anemia and bone and mineral disease improve or are even halted after KTx, kidney transplant recipients carry higher cardiovascular mortality risk than the general population, as well as an increased risk of infections, malignancies, fractures, and obesity. When comparing CKD with CKD after transplantation (CKD-T), the rate of decline of estimated glomerular filtration rate (eGFR) is significantly lower in CKD-T. Higher rate of decline of eGFR has been associated with increased risk of mortality. However, due to the significant increased risk of mortality due to cardiovascular events, infections, and malignancies, many kidney transplant recipients may not benefit of decline in the rate of eGFR. Patients with CKD-T are a unique subset of patients with multiple traditional and transplant-specific risk factors. Proper management and appropriate preventive health measures may improve long-term patient and allograft survival in patients with CKD-T.

Evolution and Determinants of Health-Related Quality-of-Life in Kidney Transplant Patients Over the First 3 Years After Transplantation

BACKGROUND

Health-related quality of life (HRQOL) usually improved after kidney transplantation; however, a non-negligible number of patients did not benefit from transplantation in HRQOL. The aims of this cohort study were to describe the evolution of HRQOL in kidney transplant recipients to search for subgroups with distinct time profiles and to investigate these determinants.

METHODS

Three hundred thirty-seven adult patients were followed up from 1 to 36 months after kidney transplantation. Each patient completed repeated HRQOL assessments (median, 5; range, 2-9). K-means for longitudinal data was used to identify homogeneous clusters of HRQOL time profiles obtained for the mental and physical composite scores (MCS and PCS) and for the 8 dimensions of the short-form 36 scale. Covariates associated with these clusters were investigated using random forest analysis. Magnitude and shape of the HRQOL variations over time were investigated using linear regression mixed models.

RESULTS

Two longitudinal clusters were identified for the time profiles of PCS and MCS. Patients classified in the higher cluster (ie, 60% of the population) exhibited a steady-state HRQOL, similar on average to the general population, whereas in the lower cluster, PCS and MCS scores were significantly lower than in the general population. Muscular weakness in the first year after transplantation explained 19% of the interpatient variability of PCS 3 months after transplantation, whereas associated with anxiety, it explained 24% of interpatient MCS variability.

CONCLUSIONS

This work suggests to promote (i) physical rehabilitation programs after transplantation to curb the muscular loss and (ii) systematic attention to the patient's anxiety.