Contraindications to kidney transplantation: uneven grounds?

Exploring Potential Gender-Based Disparities in Referral for Transplant, Activation on the Waitlist and Kidney Transplantation in a Canadian Cohort

Introduction

In the United States, women are less likely to be referred, activated on the waitlist, or undergo kidney transplant (KT) than men; contemporary Canadian data regarding access to transplant for women are lacking.

Methods

Among patients initiating dialysis in Nova Scotia (NS), Canada from 2010 to 2020, we examined the association of candidate gender with overall access to KT, including the following: (i) odds of transplant referral within 1 year of dialysis initiation, (ii) odds of activation on the transplant waitlist (if referred), and (iii) time-to-transplantation (if activated) using logistic regression or Cox proportional hazards models as appropriate.

Results

Among 749 patients deemed potentially eligible for transplant, women had lower transplant rates than men (adjusted hazard ratio [aHR]: 0.53, 95% confidence interval [CI]: 0.36-0.78); this was amplified among patients aged >60 years (aHR: 0.25, 95% CI: 0.09-0.69). Compared with men, women had a lower adjusted odds of transplant referral (adjusted odds ratio [aOR]: 0.57, 95% CI: 0.35-0.93) by 1 year after dialysis initiation. Among those referred, women had lower odds of waitlist activation than men (aOR: 0.58, 95% CI: 0.30-1.11); and among those activated, women had lower hazard of KT (aHR: 0.74, 95% CI: 0.51-1.09), though these differences were not statistically significant. Women in NS experience lower overall access to transplant, including less referral, activation and KT compared with men.

Conclusion

Gender-based barriers to any of (or in this case each of) referral, activation, or transplantation result in inequities in access; identification of disparities at these critical decision points is an important first step toward ensuring equal access for all.

Frailty and the Kidney Transplant Wait List: Protocol for a Multicenter Prospective Study

Background:

Understanding how frailty affects patients listed for transplantation has been identified as a priority research need. Frailty may be associated with a high risk of death or wait-list withdrawal, but this has not been evaluated in a large multicenter cohort of Canadian wait-listed patients.

Objective:

The primary objective is to evaluate whether frailty is associated with death or permanent withdrawal from the transplant wait list. Secondary objectives include assessing whether frailty is associated with hospitalization, quality of life, and the probability of being accepted to the wait list.

Design:

Prospective cohort study.

Setting:

Seven sites with established renal transplant programs that evaluate patients for the kidney transplant wait list.

Patients:

Individuals who are being considered for the kidney transplant wait list.

Measurements:

We will assess frailty using the Fried Phenotype, a frailty index, the Short Physical Performance Battery, and the Clinical Frailty Scale at the time of listing for transplantation. We will also assess frailty at the time of referral to the wait list and annually after listing in a subgroup of patients.

Methods:

The primary outcome of the composite of time to death or permanent wait-list withdrawal will be compared between patients who are frail and those who are not frail and will account for the competing risks of deceased and live donor transplantation. Secondary outcomes will include number of hospitalizations and length of stay, and in a subset, changes in frailty severity over time, change in quality of life, and the probability of being listed. Recruitment of 1165 patients will provide >80% power to identify a relative hazard of ≥1.7 comparing patients who are frail to those who are not frail for the primary outcome (2-sided α = .05), whereas a more conservative recruitment target of 624 patients will provide >80% power to identify a relative hazard of ≥2.0.

Results:

Through December 2019, 665 assessments of frailty (inclusive of those for the primary outcome and all secondary outcomes including repeated measures) have been completed.

Limitations:

There may be variation across sites in the processes of referral and listing for transplantation that will require consideration in the analysis and results.

Conclusions:

This study will provide a detailed understanding of the association between frailty and outcomes for wait-listed patients. Understanding this association is necessary before routinely measuring frailty as part of the wait-list eligibility assessment and prior to ascertaining the need for interventions that may modify frailty.

Trial Registration:

Not applicable as this is a protocol for a prospective observational study.

Frailty Screening in Chronic Kidney Disease: Current Perspectives

Frailty has been defined as a state of increased vulnerability as a consequence of deficit accumulation. Frailty screening has not yet been widely implemented into routine nephrology care. Patients with chronic kidney disease (CKD) are at high risk of being frail, and frailty has been associated with worse outcomes in this population. Standard management of CKD, including initiation of renal replacement therapies, may have decreased benefit or potentially cause harm in the presence of frailty, and a variety of interventions for modifying frailty in the CKD population have been proposed. The optimal means of screening for frailty in patients with kidney disease remains unclear. This review highlights the value of frailty screening in CKD by summarizing the outcomes associated with frailty and exploring proposed changes to the management of frail patients with CKD. Finally, we will propose a framework for how to implement frailty screening into standard nephrology care.

Weight Loss in Advanced Chronic Kidney Disease: Should We Consider Individualised, Qualitative, ad Libitum Diets? A Narrative Review and Case Study

In advanced chronic kidney disease, obesity may bring a survival advantage, but many transplant centres demand weight loss before wait-listing for kidney graft. The case here described regards a 71-year-old man, with obesity-related glomerulopathy; referral data were: weight 110 kg, Body Mass Index (BMI) 37 kg/m², serum creatinine (sCr) 5 mg/dL, estimated glomerular filtration rate (eGFR) 23 mL/min, blood urea nitrogen (BUN) 75 mg/dL, proteinuria 2.3 g/day. A moderately restricted, low-protein diet allowed reduction in BUN (45–55 mg/dL) and good metabolic and kidney function stability, with a weight increase of 6 kg. Therefore, he asked to be enrolled in a weight-loss program to be wait-listed (the two nearest transplant centres required a BMI below 30 or 35 kg/m²). Since previous low-calorie diets were not successful and he was against a surgical approach, we chose a qualitative, ad libitum coach-assisted diet, freely available in our unit. In the first phase, the diet is dissociated; he lost 16 kg in 2 months, without need for dialysis. In the second maintenance phase, in which foods are progressively combined, he lost 4 kg in 5 months, allowing wait-listing. Dialysis started one year later, and was followed by weight gain of about 5 kg. He resumed the maintenance diet, and his current body weight, 35 months after the start of the diet, is 94 kg, with a BMI of 31.7 kg/m², without clinical or biochemical signs of malnutrition. This case suggests that our patients can benefit from the same options available to non-CKD (chronic kidney disease) individuals, provided that strict multidisciplinary surveillance is assured.

Current practices in coronary artery disease evaluation of renal transplant candidates prior to renal transplantation

Cardiovascular disease is the leading cause of morbidity and mortality in renal transplant recipients and candidates awaiting transplant. Pre-transplant coronary artery disease evaluation can aid in determining transplant candidacy, identifying patients who may benefit from pre-operative cardiac intervention, and implementing measures to reduce perioperative and post-transplant cardiovascular events. However, the choice of investigations and approach in evaluation has yet to be well defined. This article aims to review the evidence for the use of non-invasive investigations and coronary angiography in prognostication, as well as the evidence for revascularization in reducing future cardiac events. The article will also summarize international recommendations and describe the local practice in coronary artery disease evaluation prior to transplant.