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Reddy YNV, Kearney MD, Ward M, Burke RE, O'Hare AM, Reese PP, Lane-Fall MB. Identifying Major Barriers to Home Dialysis (The IM-HOME Study): Findings From a National Survey of Patients, Care Partners, and Providers. Am J Kidney Dis 2024:S0272-6386(24)00790-X. [PMID: 38851446 DOI: 10.1053/j.ajkd.2024.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 03/22/2024] [Accepted: 04/04/2024] [Indexed: 06/10/2024]
Abstract
RATIONALE & OBJECTIVE Developing strategies to improve home dialysis use requires a comprehensive understanding of barriers. We sought to identify the most important barriers to home dialysis use from the perspective of patients, care partners, and providers. STUDY DESIGN This is a convergent parallel mixed-methods study. SETTING & PARTICIPANTS We convened a seven-member advisory board of patients, care partners, and providers who collectively developed lists of major patient/care partner-perceived barriers and provider-perceived barriers to home dialysis. We used these lists to develop a survey that was distributed to patients, care partners, and providers-through the American Association of Kidney Patients and the National Kidney Foundation. The surveys asked participants to: 1) rank their top three major barriers (quantitative); and 2) describe barriers to home dialysis (qualitative). ANALYTICAL APPROACH We compiled a list of the top three patient/care partner-perceived and top three provider-perceived barriers (quantitative) and conducted a directed content analysis of open-ended survey responses (qualitative). RESULTS There were 522 complete responses (233 providers; 289 patients/care partners). The top three patient/care partner-perceived barriers were: fear of performing home dialysis; lack of space; and the need for home-based support. The top three provider-perceived barriers were: poor patient education; limited mechanisms for home-based support staff, mental health, and education; and lack of experienced staff. We identified nine themes through qualitative analysis: limited education; financial disincentives; limited resources; high burden of care; built environment/structure of care delivery that favor in-center hemodialysis; fear and isolation; perceptions of inequities in access to home dialysis; provider perspectives about patients; and patient/provider resiliency. LIMITATIONS This was an online survey that is subject to non-response bias. CONCLUSIONS The top three barriers to home dialysis for patient/care partners and providers incompletely overlap, suggesting the need for diverse strategies that simultaneously address patient-perceived barriers at home and provider-perceived barriers in the clinic.
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Affiliation(s)
- Yuvaram N V Reddy
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Matthew D Kearney
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Mixed Methods Research Lab, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michaela Ward
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Mixed Methods Research Lab, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert E Burke
- Center for Health Equity Research and Promotion, Corporal Crescenz VA Medical Center, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; Divisions of General Internal Medicine and Hospital Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ann M O'Hare
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington; Hospital and Specialty Medicine and Geriatrics and Extended Care Services, VA Puget Sound Health Care System, Seattle, Washington; Department of Medicine, University of Washington, Seattle, Washington
| | - Peter P Reese
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Meghan B Lane-Fall
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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2
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Kim I, Maggiore U, Knight SR, Rana Magar R, Pengel LHM, Dor FJMF. Pre-emptive living donor kidney transplantation: A public health justification to change the default. Front Public Health 2023; 11:1124453. [PMID: 37006536 PMCID: PMC10063978 DOI: 10.3389/fpubh.2023.1124453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 02/28/2023] [Indexed: 03/19/2023] Open
Affiliation(s)
- Isaac Kim
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Umberto Maggiore
- Dipartimento di Medicina e Chirurgia, Università di Parma, Unità Operativa Nefrologia, Azienda Ospedaliera-Universitaria Parma, Parma, Italy
| | - Simon R. Knight
- Sir Peter Morris Centre for Evidence in Transplantation, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Reshma Rana Magar
- Sir Peter Morris Centre for Evidence in Transplantation, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Liset H. M. Pengel
- Sir Peter Morris Centre for Evidence in Transplantation, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Frank J. M. F. Dor
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
- *Correspondence: Frank J. M. F. Dor
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3
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Olarte Parra C, Waernbaum I, Schön S, Goetghebeur E. Trial emulation and survival analysis for disease incidence registers: A case study on the causal effect of pre-emptive kidney transplantation. Stat Med 2022; 41:4176-4199. [PMID: 35808992 PMCID: PMC9543809 DOI: 10.1002/sim.9503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 05/15/2022] [Accepted: 06/01/2022] [Indexed: 11/30/2022]
Abstract
When drawing causal inference from observed data, failure time outcomes present additional challenges of censoring often combined with other missing data patterns. In this article, we follow incident cases of end‐stage renal disease to examine the effect on all‐cause mortality of starting treatment with transplant, so‐called pre‐emptive kidney transplantation, vs starting with dialysis possibly followed by delayed transplantation. The question is relatively simple: which start‐off treatment is expected to bring the best survival for a target population? To address it, we emulate a target trial drawing on the long term Swedish Renal Registry, where a growing common set of baseline covariates was measured nationwide. Several lessons are learned which pertain to long term disease registers more generally. With characteristics of cases and versions of treatment evolving over time, informative censoring is already introduced in unadjusted Kaplan‐Meier curves. This leads to misrepresented survival chances in observed treatment groups. The resulting biased treatment association may be aggravated upon implementing IPW for treatment. Aware of additional challenges, we further recall how similar studies to date have selected patients into treatment groups based on events occurring post treatment initiation. Our study reveals the dramatic impact of resulting immortal time bias combined with other typical features of long‐term incident disease registers, including missing covariates during the early phases of the register. We discuss feasible ways of accommodating these features when targeting relevant estimands, and demonstrate how more than one causal question can be answered relying on the no unmeasured baseline confounders assumption.
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Affiliation(s)
- Camila Olarte Parra
- Department of Applied Mathematics, Computer Science and Statistics, Ghent University, Ghent, Belgium.,Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academisch Medisch Centrum, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Staffan Schön
- Swedish Renal Registry, Jönköping County Hospital, Jönköping, Sweden
| | - Els Goetghebeur
- Department of Applied Mathematics, Computer Science and Statistics, Ghent University, Ghent, Belgium
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4
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Redeker S, Massey EK, van Merweland RG, Weimar W, Ismail S, Busschbach J. Induced Demand in Kidney Replacement Therapy. Health Policy 2022; 126:1062-1068. [DOI: 10.1016/j.healthpol.2022.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 07/23/2022] [Accepted: 07/28/2022] [Indexed: 11/25/2022]
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Adekunle RO, Zhang R, Wang Z, Patzer RE, Mehta AK. Early steps to kidney transplantation among persons with HIV and end-stage renal disease in ESRD network 6. Transpl Infect Dis 2022; 24:e13767. [PMID: 34813136 PMCID: PMC8825692 DOI: 10.1111/tid.13767] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 10/18/2021] [Accepted: 11/10/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION End-stage renal disease is a significant cause of morbidity and mortality in persons with HIV (PWH). Limited data exist on access to kidney transplantation for this population. METHODS A dataset inclusive of incident dialysis patients between 2012 and 2016 with follow-up through December 2017 that identifies PWH and the general dialysis population of Network 6 (Georgia, North Carolina, South Carolina) was created through merging the United States Renal Data System with the southeastern early transplant access registry. Early steps to kidney transplantation and patient and dialysis facility-level characteristics that serve as barriers to transplantation were described. RESULTS Twenty-three thousand four hundred fourteen patients were identified; 469 were PWH. Compared to non-HIV individuals, PWH were younger (49 vs. 58 years, p < 0.001), predominantly Black (87% vs. 56% p < 0.001) and male (72% vs. 56% p < 0.001). PWH were less likely to be referred to kidney transplant within 1 year of starting dialysis (36% vs. 41% p < 0.001) and waitlisted within 1 year of evaluation-start (14% vs. 30%, p = 0.05). PWH (vs. non-PWH) waited longer for referral, evaluation-start, and waitlisting and in multivariable analysis; HIV positivity was associated with a lower probability of referral (hazard ratios [HR]: 0.70; 95% confidence intervals [CIs]: 0.62-0.80), evaluation (HR 0.66; 95% CI: 0.55-0.80), and waitlisting (HR 0.29; 95% CI: 0.20-0.41). CONCLUSIONS Targeted interventions are needed to improve access to kidney transplants, particularly in waitlisting, for PWH.
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Affiliation(s)
- Ruth O Adekunle
- Division of Infectious Diseases, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Rebecca Zhang
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Zhengsheng Wang
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Rachel E Patzer
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Aneesh K Mehta
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, Georgia Emory Transplant Center, Atlanta, Georgia,Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
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6
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Dirix M, Philipse E, Vleut R, Hartman V, Bracke B, Chapelle T, Roeyen G, Ysebaert D, Van Beeumen G, Snelders E, Massart A, Leyssens K, Couttenye MM, Abramowicz D, Hellemans R. OUP accepted manuscript. Clin Kidney J 2022; 15:1100-1108. [PMID: 35664264 PMCID: PMC9155241 DOI: 10.1093/ckj/sfac006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Indexed: 11/15/2022] Open
Affiliation(s)
| | - Ester Philipse
- Department of Nephrology, Antwerp University Hospital, Antwerp, Belgium
- Laboratory of Experimental Medicine and Paediatrics, University of Antwerp, Antwerp, Belgium
| | - Rowena Vleut
- Department of Nephrology, Antwerp University Hospital, Antwerp, Belgium
- Laboratory of Experimental Medicine and Paediatrics, University of Antwerp, Antwerp, Belgium
| | - Vera Hartman
- Department of Hepatobiliary, Transplantation and Endocrine Surgery, Antwerp University Hospital, Antwerp, Belgium
| | - Bart Bracke
- Department of Hepatobiliary, Transplantation and Endocrine Surgery, Antwerp University Hospital, Antwerp, Belgium
| | - Thierry Chapelle
- Department of Hepatobiliary, Transplantation and Endocrine Surgery, Antwerp University Hospital, Antwerp, Belgium
| | - Geert Roeyen
- Department of Hepatobiliary, Transplantation and Endocrine Surgery, Antwerp University Hospital, Antwerp, Belgium
| | - Dirk Ysebaert
- Department of Hepatobiliary, Transplantation and Endocrine Surgery, Antwerp University Hospital, Antwerp, Belgium
| | - Gerda Van Beeumen
- Department of Nephrology, Antwerp University Hospital, Antwerp, Belgium
- Department of Hepatobiliary, Transplantation and Endocrine Surgery, Antwerp University Hospital, Antwerp, Belgium
| | - Erik Snelders
- Department of Nephrology, Antwerp University Hospital, Antwerp, Belgium
- Laboratory of Experimental Medicine and Paediatrics, University of Antwerp, Antwerp, Belgium
| | - Annick Massart
- Department of Nephrology, Antwerp University Hospital, Antwerp, Belgium
- Laboratory of Experimental Medicine and Paediatrics, University of Antwerp, Antwerp, Belgium
| | - Katrien Leyssens
- Department of Nephrology, Antwerp University Hospital, Antwerp, Belgium
| | - Marie M Couttenye
- Department of Nephrology, Antwerp University Hospital, Antwerp, Belgium
- Laboratory of Experimental Medicine and Paediatrics, University of Antwerp, Antwerp, Belgium
| | - Daniel Abramowicz
- Department of Nephrology, Antwerp University Hospital, Antwerp, Belgium
- Laboratory of Experimental Medicine and Paediatrics, University of Antwerp, Antwerp, Belgium
| | - Rachel Hellemans
- Department of Nephrology, Antwerp University Hospital, Antwerp, Belgium
- Laboratory of Experimental Medicine and Paediatrics, University of Antwerp, Antwerp, Belgium
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7
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van Dellen D, Burnapp L, Citterio F, Mamode N, Moorlock G, van Assche K, Zuidema WC, Lennerling A, Dor FJMF. Pre-emptive live donor kidney transplantation-moving barriers to opportunities: An ethical, legal and psychological aspects of organ transplantation view. World J Transplant 2021; 11:88-98. [PMID: 33954087 PMCID: PMC8058646 DOI: 10.5500/wjt.v11.i4.88] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 01/30/2021] [Accepted: 03/12/2021] [Indexed: 02/06/2023] Open
Abstract
Live donor kidney transplantation (LDKT) is the optimal treatment modality for end stage renal disease (ESRD), enhancing patient and graft survival. Pre-emptive LDKT, prior to requirement for renal replacement therapy (RRT), provides further advantages, due to uraemia and dialysis avoidance. There are a number of potential barriers and opportunities to promoting pre-emptive LDKT. Significant infrastructure is needed to deliver robust programmes, which varies based on socio-economic standards. National frameworks can impact on national prioritisation of pre-emptive LDKT and supporting education programmes. Focus on other programme’s components, including deceased kidney transplantation and RRT, can also hamper uptake. LDKT programmes are designed to provide maximal benefit to the recipient, which is specifically true for pre-emptive transplantation. Health care providers need to be educated to maximize early LDKT referral. Equitable access for varying population groups, without socio-economic bias, also requires prioritisation. Cultural barriers, including religious influence, also need consideration in developing successful outcomes. In addition, the benefit of pre-emptive LDKT needs to be emphasised, and opportunities provided to potential donors, to ensure timely and safe work-up processes. Recipient education and preparation for pre-emptive LDKT needs to ensure increased uptake. Awareness of the benefits of pre-emptive transplantation require prioritisation for this population group. We recommend an approach where patients approaching ESRD are referred early to pre-transplant clinics facilitating early discussion regarding pre-emptive LDKT and potential donors for LDKT are prioritized for work-up to ensure success. Education regarding pre-emptive LDKT should be the norm for patients approaching ESRD, appropriate for the patient’s cultural needs and physical status. Pre-emptive transplantation maximize benefit to potential recipients, with the potential to occur within successful service delivery. To fully embrace preemptive transplantation as the norm, investment in infrastructure, increased awareness, and donor and recipient support is required.
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Affiliation(s)
- David van Dellen
- Department of Renal and Pancreas Transplantation, Manchester University NHS Foundation Trust, Manchester M13 9WL, United Kingdom
- Department of Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, United Kingdom
| | - Lisa Burnapp
- Department of Transplantation, Guy's and St. Thomas' NHS Foundation Trust, London SE1 9RT, United Kingdom
| | - Franco Citterio
- Department of Surgery, Renal Transplantation, Catholic University, Rome 00153, Italy
| | - Nizam Mamode
- Department of Transplantation, Guy's and St. Thomas' NHS Foundation Trust, London SE1 9RT, United Kingdom
| | - Greg Moorlock
- Warwick Medical School, University of Warwick, Coventry CV4 7AL, United Kingdom
| | - Kristof van Assche
- Res Grp Personal Rights & Property Rights, University of Antwerp, Antwerp 2000, Belgium
| | - Willij C Zuidema
- Departments of Internal Medicine, Erasmus Medical Centre, Rotterdam CE 1015, Netherlands
| | - Annette Lennerling
- The Transplant Centre, Sahlgrenska University Hospital, Gothenburg S-413 45, Sweden
- Institute of Health and Care Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg S-405 30, Sweden
| | - Frank JMF Dor
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, London W2 1NY, United Kingdom
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8
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Habbous S, Barnieh L, Litchfield K, McKenzie S, Reich M, Lam NN, Mucsi I, Bugeja A, Yohanna S, Mainra R, Chong K, Fantus D, Prasad GVR, Dipchand C, Gill J, Getchell L, Garg AX. A RAND-Modified Delphi on Key Indicators to Measure the Efficiency of Living Kidney Donor Candidate Evaluations. Clin J Am Soc Nephrol 2020; 15:1464-1473. [PMID: 32972951 PMCID: PMC7536753 DOI: 10.2215/cjn.03780320] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 07/16/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVES Many patients, providers, and potential living donors perceive the living kidney donor evaluation process to be lengthy and difficult to navigate. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We sought consensus on key terms and process and outcome indicators that can be used to measure how efficiently a transplant center evaluates persons interested in becoming a living kidney donor. Using a RAND-modified Delphi method, 77 participants (kidney transplant recipients or recipient candidates, living kidney donors or donor candidates, health care providers, and health care administrators) completed an online survey to define the terms and indicators. The definitions were then further refined during an in-person meeting with ten stakeholders. RESULTS We identified 16 process indicators (e.g., average time to evaluate a donor candidate), eight outcome indicators (e.g., annual number of preemptive living kidney donor transplants), and two measures that can be considered both process and outcome indicators (e.g., average number of times a candidate visited the transplant center for the evaluation). Transplant centers wishing to implement this set of indicators will require 22 unique data elements, all of which are either readily available or easily collected prospectively. CONCLUSIONS We identified a set of indicators through a consensus-based approach that may be used to monitor and improve the performance of a transplant center in how efficiently it evaluates persons interested in becoming a living kidney donor.
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Affiliation(s)
- Steven Habbous
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada .,Quality, Measurement, and Evaluation, Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada
| | - Lianne Barnieh
- Department of Nephrology, London Health Sciences Centre, London, Ontario, Canada
| | - Kenneth Litchfield
- Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease, Canada
| | - Susan McKenzie
- Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease, Canada
| | - Marian Reich
- Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease, Canada
| | - Ngan N Lam
- Division of Nephrology, University of Calgary, Calgary, Alberta, Canada
| | - Istvan Mucsi
- Kidney Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Ann Bugeja
- Division of Nephrology, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Seychelle Yohanna
- Division of Nephrology, McMaster University, Hamilton, Ontario, Canada
| | - Rahul Mainra
- Saskatchewan Transplant Program, Saskatoon Health Region, Saskatoon, Saskatchewan, Canada
| | - Kate Chong
- Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease, Canada
| | - Daniel Fantus
- Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - G V Ramesh Prasad
- Kidney Transplant Program, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Christine Dipchand
- Division of Nephrology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jagbir Gill
- Division of Nephrology, St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Leah Getchell
- Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease, Canada
| | - Amit X Garg
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada.,Department of Nephrology, London Health Sciences Centre, London, Ontario, Canada
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9
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Sandal S, Charlebois K, Fiore JF, Wright DK, Fortin MC, Feldman LS, Alam A, Weber C. Health Professional-Identified Barriers to Living Donor Kidney Transplantation: A Qualitative Study. Can J Kidney Health Dis 2019; 6:2054358119828389. [PMID: 30792874 PMCID: PMC6376531 DOI: 10.1177/2054358119828389] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 12/18/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Living donor kidney transplantation (LDKT) has several advantages over deceased donor kidney transplantation. Yet rates of living donation are declining in Canada and there exists significant interprovincial variability. Efforts to improve living donation tend to focus on the patient and barriers identified at their level, such as not knowing how to ask for a kidney or lack of education. These efforts favor those who have the means and the support to find living donors. Thus, a Canadian Institutes of Health Research (CIHR)-organized workshop recommended that education efforts to understand and remove barriers should focus on health professionals (HPs). Despite this, little attention has been paid to what they identify as barriers to discussing LDKT with their patients. OBJECTIVE Our aim was to explore HP-identified barriers to discuss living donation with patients in 3 provinces of Canada with low (Quebec), moderate (Ontario), and high (British Columbia) rates of LDKT. DESIGN This study consists of an interpretive descriptive approach as it enables to move beyond description and inform clinical practice. SETTING Purposive criterion and quota sampling were used to recruit HPs from Quebec, Ontario, and British Columbia who are involved in the care of patients with kidney disease and/or with transplant coordination. PATIENTS Not applicable. MEASUREMENTS Semistructured interviews were conducted. The interview guide was developed based on a preliminary analytical framework and a review of the literature. METHODS Thematic analysis was used to analyze the data stemming from the interviews. The coding process comprised of a deductive and inductive approach, and the use of a qualitative analysis software (NVivo 11). Following this, themes were identified and developed. Interviews were conducted until thematic saturation was obtained. In total, we conducted 16 telephone interviews as thematic saturation was attained. RESULTS Six predominant themes emerged: (1) lack of communication between transplant and dialysis teams, (2) absence of referral guidelines, (3) role perception and lack of multidisciplinary involvement, (4) HP's lack of information and training, (5) negative attitudes of some HP toward LDKT, (6) patient-level barriers as defined by the HP. HPs did mention patients' attitudes and some characteristics as the main barriers to discussions about living donation; this was noted in all provinces. HPs from Ontario and British Columbia indicated multiple strategies being implemented to address some of these barriers. Those from Ontario mentioned strategies that center on the core principles of provincial-level standardization, while those from British Columbia center on engaging the entire multidisciplinary team and improved role perception. We noted a dearth of such efforts in Quebec; however, efforts around education and promotion, while tentative, have emerged. LIMITATIONS Social desirability and selection bias. Our analysis might not be applicable to other provinces. CONCLUSIONS HPs involved with the referral and coordination of transplantation play a major role in access to LDKT. We have identified challenges they face when discussing living donation with their patients that warrant further assessment and research to inform policy change.
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Affiliation(s)
- Shaifali Sandal
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
- Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | | | - Julio F. Fiore
- Research Institute of the McGill University Health Centre, Montreal, QC, Canada
- Department of Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - David Kenneth Wright
- St. Mary’s Research Center, Montreal, QC, Canada
- School of Nursing, University of Ottawa, Ottawa, ON, Canada
| | - Marie-Chantal Fortin
- Division of Nephrology, Department of Medicine, Centre hospitalier de l’Université de Montréal, Montreal, QC, Canada
- Centre de recherche du Centre hospitalier de l’Université de Montréal, Montreal, QC, Canada
| | - Liane S. Feldman
- Department of Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - Ahsan Alam
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - Catherine Weber
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
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10
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Olarte Parra C, Van de Bruaene C, Weynants L, Nagler EV, McAleenan A, Elbers RG, Higgins JPT, Goetghebeur E. Pre-emptive versus non pre-emptive kidney transplantation for end-stage kidney disease. Hippokratia 2018. [DOI: 10.1002/14651858.cd013073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Camila Olarte Parra
- Ghent University; Department of Applied Mathematics, Computer Science and Statistics; Campus Sterre, S9, Krijgslaan 281 Ghent East Flanders Belgium 9000
| | - Cedric Van de Bruaene
- Ghent University Hospital; Department of Internal Medicine; De Pintelaan 185 Ghent East Flanders Belgium 9000
| | - Laurens Weynants
- Ghent University Hospital; Department of Urology; De Pintelaan 185 Ghent East Flanders Belgium 9000
| | - Evi V Nagler
- Ghent University Hospital; Renal Division, Sector Metabolic and Cardiovascular Conditions; De Pintelaan 185 Ghent Belgium 9000
| | - Alexandra McAleenan
- University of Bristol; Population Health Sciences, Bristol Medical School; 39 Whatley Road Bristol UK BS8 2PS
| | - Roy G Elbers
- University of Bristol; Population Health Sciences, Bristol Medical School; 39 Whatley Road Bristol UK BS8 2PS
| | - Julian P T Higgins
- University of Bristol; Population Health Sciences, Bristol Medical School; 39 Whatley Road Bristol UK BS8 2PS
| | - Els Goetghebeur
- Ghent University; Department of Applied Mathematics, Computer Science and Statistics; Campus Sterre, S9, Krijgslaan 281 Ghent East Flanders Belgium 9000
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11
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Habbous S, McArthur E, Sarma S, Begen MA, Lam NN, Manns B, Lentine KL, Dipchand C, Litchfield K, McKenzie S, Garg AX. Potential implications of a more timely living kidney donor evaluation. Am J Transplant 2018; 18:2719-2729. [PMID: 29575655 DOI: 10.1111/ajt.14732] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 02/08/2018] [Accepted: 03/05/2018] [Indexed: 01/25/2023]
Abstract
Living donor kidney transplantation is the most promising way to avoid or minimize the amount of time a recipient spends on dialysis before transplantation. We studied 887 living kidney donors at 5 transplant centers in Ontario, Canada, who started their evaluation and donated between April 2006 and March 2014. Using a series of hypothetical scenarios, we estimated the impact of an earlier living donor evaluation completion and donation on the number pre-emptive transplants, the time spent on dialysis, healthcare cost savings from averted dialysis costs (CAD $2016), and the number of additional transplants. During the study period, if the donor transplants occurred 3 months earlier, the healthcare system would save on average $12 055 (standard deviation [SD] $13 594) per recipient; 21 recipients could have avoided dialysis altogether, and 57 additional transplants (a 26% increase) could have occurred each year. For the 220 living kidney donor transplants performed in Ontario, Canada, each year, this translates to a total annual cost savings of $2.7M. In conclusion, a more timely evaluation of living donor candidates and their intended recipients may increase the supply of kidneys for transplantation. Improved evaluation efficiency may also yield more pre-emptive transplants and substantial healthcare cost savings through averted dialysis costs.
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Affiliation(s)
- Steven Habbous
- Department of Epidemiology & Biostatistics, Western University, London, ON, Canada
| | - Eric McArthur
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Sisira Sarma
- Department of Epidemiology & Biostatistics, Western University, London, ON, Canada
| | - Mehmet A Begen
- Department of Epidemiology & Biostatistics, Western University, London, ON, Canada.,Ivey School of Business, Western University, London, ON, Canada
| | - Ngan N Lam
- University of Alberta, Edmonton, AB, Canada
| | - Braden Manns
- Departments of Medicine and Community Health Sciences, O'Brien Institute for Public Health, Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
| | - Krista L Lentine
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, MO, USA
| | | | - Kenneth Litchfield
- Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease (CAN-SOLVE CKD) patient council, London, ON, Canada
| | - Susan McKenzie
- Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease (CAN-SOLVE CKD) patient council, London, ON, Canada.,Kidney Foundation of Canada, London, ON, Canada
| | - Amit X Garg
- Department of Epidemiology & Biostatistics, Western University, London, ON, Canada.,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada.,Division of Nephrology, Department of Medicine, Western University, London, ON, Canada
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12
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Comparative Study on Variation of Quality of Life of Patients of Preemptive Kidney Transplantation and Nonpreemptive Kidney Transplantation. Transplant Proc 2018; 50:3321-3328. [PMID: 30577202 DOI: 10.1016/j.transproceed.2018.08.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 08/29/2018] [Indexed: 11/21/2022]
Abstract
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.
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13
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Chaudhry RI, Mathew RO, Sidhu MS, Sidhu-Adler P, Lyubarova R, Rangaswami J, Salman L, Asif A, Fleg JL, McCullough PA, Maddux F, Bangalore S. Detection of Atherosclerotic Cardiovascular Disease in Patients with Advanced Chronic Kidney Disease in the Cardiology and Nephrology Communities. Cardiorenal Med 2018; 8:285-295. [PMID: 30078001 DOI: 10.1159/000490768] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 06/10/2018] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Atherosclerotic cardiovascular disease (ASCVD) is a leading cause of morbidity and mortality among patients with chronic kidney disease (CKD) with a glomerular filtration rate of < 60 mL/min/1.73 m2 body surface area. The availability of high-quality randomized controlled trial data to guide management for the population with CKD and ASCVD is limited. Understanding current practice patterns among providers caring for individuals with CKD and CVD is important in guiding future trial questions. METHODS A qualitative survey study was performed. An electronic survey regarding the diagnosis and management of CVD in patients with CKD was conducted using a convenience sample of 450 practicing nephrology and cardiology providers. The survey was administered using Qualtrics® (https://www.qualtrics.com). RESULTS There were a total of 113 responses, 81 of which were complete responses. More than 90% of the respondents acknowledged the importance of CVD as a cause of morbidity and mortality in patients with CKD. Outside the kidney transplant evaluation setting, 5% of the respondents would screen an asymptomatic patient with advanced CKD for ASCVD. Outside the kidney transplant evaluation scenario, the respondents did not opt for invasive management strategies in advanced CKD. CONCLUSIONS The survey results reveal a lack of consensus among providers caring for patients with advanced CKD about the management of ASCVD in this setting. Future randomized controlled trials will be needed to better inform the clinical management of ASCVD in these patients. The limitations of the study include its small sample size and the relatively low response rate among the respondents.
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Affiliation(s)
- Rafia I Chaudhry
- Division of Nephrology and Hypertension, Albany Medical College, Albany, New York, USA
| | - Roy O Mathew
- Division of Nephrology, WJB Dorn VA Medical Center, Columbia, South Carolina, USA
| | - Mandeep S Sidhu
- Division of Cardiology, Albany Medical College, Albany, New York, USA
| | | | - Radmila Lyubarova
- Division of Cardiology, Albany Medical College, Albany, New York, USA
| | - Janani Rangaswami
- Division of Nephrology, Department of Medicine, Einstein Medical Center, Philadelphia, Pennsylvania, USA
| | - Loay Salman
- Division of Nephrology and Hypertension, Albany Medical College, Albany, New York, USA
| | - Arif Asif
- Department of Medicine, Jersey Shore University Medical Center, Seton Hall-Hackensack Meridian School of Medicine, Neptune City, New Jersey, USA
| | - Jerome L Fleg
- Division of Cardiovascular Sciences, National Heart, Lung and Blood Institute, Bethesda, Maryland, USA
| | | | - Frank Maddux
- Fresenius Medical Care North America, Waltham, Massachusetts, USA
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14
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Identifying Barriers to Preemptive Kidney Transplantation in a Living Donor Transplant Cohort. Transplant Direct 2018; 4:e356. [PMID: 29707627 PMCID: PMC5908459 DOI: 10.1097/txd.0000000000000773] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 01/19/2018] [Indexed: 11/26/2022] Open
Abstract
Background Despite substantial evidence demonstrating clear benefit, rates of preemptive kidney transplantation (PreKTx) remain low in the United States. Our goal was to identify barriers to PreKTx. Methods Using a telephone-administered questionnaire including questions about barriers, timing of referral, timing of education, we retrospectively studied first living donor kidney transplant recipients (2006-2010) at Mayo Clinic, Rochester, MN. Of 235 patients, 145 (62%) responded to the questionnaire (74 PreKTx and 71 non-PreKTx). We compared categorical data with Fisher exact test and median times with Wilcoxon rank sum test. Results Polycystic kidney disease (PCKD), longer median time between diagnosis and transplant, and time between education about transplant and transplant correlated with PreKTx (P < 0.01). The presence of at least 1 patient-identified barrier (lack of referral, financial barriers, medical barriers, no identified living donor and donor evaluation delays) was associated with non-PreKTx (0.034) though no single barrier predominated. Age, education level, insurance status and source of referral (primary care, nephrology, and nonphysician referral) were not associated with the rate of PreKTx. Univariate logistic regression identified white race, PCKD, and increased time from diagnosis as factors favoring PreKTx; PCKD and increased time remained significant factors after multivariate analysis. Conclusions Even among a patient population that is primarily white, educated, and has a spouse or first-degree relative donor, PreKTx rates remain concerningly low. Increased time between diagnosis or education and transplant are predictors of PreKTx. Greater emphasis on transplant education earlier in the stages of chronic kidney disease and community outreach from transplant centers may help to increase the rate of PreKTx.
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15
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Nephrologists' Perspectives on Recipient Eligibility and Access to Living Kidney Donor Transplantation. Transplantation 2016; 100:943-53. [PMID: 26425873 DOI: 10.1097/tp.0000000000000921] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Wide variations in access to living kidney donation are apparent across transplant centers. Such disparities may be in part explained by nephrologists' beliefs and decisions about recipient eligibility. This study aims to describe nephrologists' attitudes towards recipient eligibility and access to living kidney donor transplantation. METHODS Face-to-face semistructured interviews were conducted from June to October 2013 with 41 nephrologists from Australia and New Zealand. Transcripts were analyzed thematically. RESULTS We identified five major themes: championing optimal recipient outcomes (maximizing recipient survival, increasing opportunity, accepting justified risks, needing control and certainty of outcomes, safeguarding psychological wellbeing), justifying donor sacrifice (confidence in reasonable utility, sparing the donor, ensuring reciprocal donor benefit), advocating for patients (being proactive and encouraging, addressing ambivalence, depending on supportive infrastructure, avoiding selective recommendations), maintaining professional boundaries (minimizing conflict of interest, respecting shared decision-making, emphasizing patient accountability, restricted decisional power, protecting unit interests), and entrenched inequities (exclusivity of living donors, inherently advantaging self-advocates, navigating language barriers, increasing center transparency, inevitable geographical disadvantage, understanding cultural barriers). CONCLUSIONS Nephrologists' decisions about recipient suitability for living donor transplantation aimed to achieve optimal recipient outcomes, but were constrained by competing priorities to ensure reasonable utility derived from the donor kidney and protect the integrity of the transplant program. Comprehensive guidelines that provide explicit recommendations for complex medical and psychosocial risk factors might promote more equitable and transparent decision-making. Psychosocial support and culturally sensitive educational resources are needed to help nephrologists advocate for disadvantaged patients and address disparities in access to living kidney donor transplantation.
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16
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Pruthi R, Casula A, Inward C, Roderick P, Sinha MD. Early Requirement for RRT in Children at Presentation in the United Kingdom: Association with Transplantation and Survival. Clin J Am Soc Nephrol 2016; 11:795-802. [PMID: 26912550 PMCID: PMC4858480 DOI: 10.2215/cjn.08190815] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Accepted: 01/29/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES We evaluated rates and factors associating with late referral (LR) and describe association of LR with access to renal transplantation and patient survival in children in the United Kingdom. Early requirement of RRT within 90 days of presentation to a pediatric nephrologist was classed as a LR, and those >90 days as an early referral (ER). DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We included patients who commenced RRT, aged ≥3 months and <16 years, from 1996 to 2012. RESULTS Of 1603 patients, 25.5% (n=408) were LR, of which 75% commenced RRT in <30 days following presentation. Those with LR were more likely to be older at presentation, female, and black. The primary renal disease in LR was more likely to be glomerular disease (odds ratio [OR], 1.6; 95% confidence interval [95% CI], 1.12 to 2.29), renal malignancy and associated diseases (OR, 4.11; 95% CI, 1.57 to 10.72), tubulo-interstitial diseases (OR, 2.37; 95% CI, 1.49 to 3.78), or an uncertain renal etiology (OR, 5.75; 95% CI, 3.1 to 10.65). Significant differences in rates of transplantation between LR and ER remained up to 1-year following commencement of dialysis (21% versus 61%, P<0.001) but with no differences for donor source (33.3% and 35.3% living donor in LR and ER respectively, P=0.55). The median (interquartile range) follow-up time was 4.8 years (2.9-7.6). There were 55 deaths with no statistically significant difference in survival in the LR group compared with the ER group (hazard ratio, 1.30; 95% CI, 0.7 to 2.3; P=0.40). CONCLUSIONS We found that 25% of children starting RRT in the United Kingdom receive a LR to pediatric renal services, with little change observed over the past two decades. Those with LR are unable to benefit from pre-emptive transplantation and require longer periods of dialysis before transplantation. There is an urgent need to understand causes of avoidable LR and develop strategies to improve kidney awareness more widely among health care professionals looking after children.
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Affiliation(s)
| | | | - Carol Inward
- Department of Paediatric Nephrology, Bristol Royal Hospital for Children, Bristol, United Kingdom
| | - Paul Roderick
- Faculty of Medicine, Primary Care and Population Sciences, University of Southampton, Southampton, United Kingdom; and
| | - Manish D. Sinha
- Department of Paediatric Nephrology, Evelina London Children’s Hospital, London, United Kingdom
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17
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Barriers to preemptive renal transplantation: a single center questionnaire study. Transplantation 2015; 99:576-9. [PMID: 25083616 DOI: 10.1097/tp.0000000000000357] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Preemptive transplantation results in excellent patient and graft survival yet most transplant candidates are referred for transplantation after initiation of dialysis. The goal of this study was to determine barriers to preemptive renal transplantation. METHODS A nonvalidated questionnaire was administered to prospective kidney transplant recipients to determine factors that hindered or favored referral for transplantation before the initiation of dialysis. RESULTS One hundred ninety-seven subjects referred for a primary renal transplant completed the questionnaire. Ninety-one subjects (46%) had been informed of preemptive transplantation before referral, and 80 (41%) were predialysis at the time of evaluation. The median time from diagnosis of renal disease to referral was 60 months (range, 2-444 months). In bivariate analysis, among other factors, knowledge of preemptive transplantation was highly associated (odds ratio=94.69) with referral before initiation of dialysis. Given the strong association between knowledge of preemptive transplantation and predialysis referral, this variable was not included in the multivariate analysis. Using multivariate logistic regression analysis, white recipient race, referral by a transplant nephrologist, recipient employment, and the diagnosis of polycystic kidney disease were significantly associated with presentation to the pretransplant clinic before initiation of dialysis. CONCLUSION The principle barrier to renal transplantation referral before dialysis was patient education regarding the option of preemptive transplantation. Factors significantly associated with referral before dialysis were the diagnosis of polycystic kidney disease, white recipient race, referral by a transplant nephrologist, and employed status. Greater effort should be applied to patient education regarding preemptive transplantation early after the diagnosis of end-stage renal disease.
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18
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The Preferences and Perspectives of Nephrologists on Patients’ Access to Kidney Transplantation. Transplantation 2014; 98:682-91. [DOI: 10.1097/tp.0000000000000336] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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19
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Ghahramani N, Karparvar Z, Ghahramani M, Shadrou S. International survey of nephrologists' perceptions and attitudes about rewards and compensations for kidney donation. Nephrol Dial Transplant 2014; 28:1610-21. [PMID: 23780679 DOI: 10.1093/ndt/gft079] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Payment for organ donation, whether in the form of incentives, rewards or compensation is highly debated and has been denounced by many professional and legislative bodies. Despite the passionate discussion in the literature, there is very limited data on attitudes and perceptions of physicians about providing rewards or compensation to organ donors. We investigated the relationship between demographic and practice characteristics of nephrologists and their perceptions and attitudes about rewards and compensations for organ donation. METHODS Using a web-based survey, we explored the views of nephrologists around the world about rewards and compensations for kidney donation. The relationship between attitudes and demographic characteristics of 1280 nephrologists from 74 countries was examined by univariate and multivariable analyses. RESULTS Seventy-five percent agreed with donor health insurance, 26% favored direct financial compensation and 31% agreed with financial rewards for unrelated donors. Sixty-six percent believed that rewards will lead to increased donation. Seventy-three percent indicated that rewards will lead to exploitation of the poor and 78% agreed with legislation prohibiting organ sales. Thirty-seven percent believed that rewards will negatively impact deceased-donor transplantation. Nephrologists from India/Pakistan and the Middle East had more favorable views about rewards, while respondents from Latin America and Europe, older than 50, female nephrologists and those practicing in rural areas had less favorable views. CONCLUSIONS We conclude that a minority of nephrologists favor rewards for donation, many agree with some compensation and a considerable majority favor donor health insurance. Perceptions of nephrologists about rewards and compensation are influenced by age, sex, urban versus rural location and geographic region of practice.
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Affiliation(s)
- Nasrollah Ghahramani
- Pennsylvania State University College of Medicine, Division of Nephrology, Hershey, PA, USA.
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20
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Pavlakis M, Kher A. Pre-emptive kidney transplantation to improve survival in patients with type 1 diabetes and imminent risk of ESRD. Semin Nephrol 2013; 32:505-11. [PMID: 23062992 DOI: 10.1016/j.semnephrol.2012.07.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Despite significant improvements in the treatment of diabetic nephropathy over the past 20 years, patients with type 1 diabetes are at high risk of developing end-stage renal disease and high mortality once end-stage renal disease develops. Type 1 diabetic patients treated with predialysis (pre-emptive) transplantation have a lower death rate than type 1 diabetic patients treated with dialysis. Living donor kidney transplantation is possible before starting dialysis and is associated with better kidney and patient outcomes as compared with transplantation while on dialysis. In addition, a variety of potential donors can be used, not just young, well-matched family members. Through paired kidney donation, blood group ABO-incompatible transplants and transplants across the barrier of anti-human leukocyte antigen antibodies, diabetic patients can receive living donor kidney transplants even if their intended donor is not a good match for them. Despite these expanded options making living donation possible, only a minority of type 1 diabetic patients receive a pre-emptive kidney transplant. Multiple barriers remain that prevent type 1 diabetic patients from enjoying the reduced risk of death afforded by a pre-emptive kidney transplant, including lack of knowledge by primary care physicians, endocrinologists, and nephrologists; late referral for transplantation; patient and family misconceptions about timing of transplantation; and who can be a donor. The vast majority of type 1 diabetic patients are listed for kidney transplantation after the initiation of dialysis. Of these patients, thousands subsequently receive a live donor kidney transplant. We believe that the appropriate agencies and societies should address the barriers to pre-emptive kidney transplantation through nationwide educational initiatives and study the causes of failure to be transplanted before dialysis initiation.
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Affiliation(s)
- Martha Pavlakis
- Renal Division and the Transplant Institute at Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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21
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Ficorelli CT, Edelman M, Weeks BH. Living donor renal transplant: a gift of life. Nursing 2012; 43:58-62. [PMID: 23254882 DOI: 10.1097/01.nurse.0000423962.53249.b1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Despite significant improvements in the treatment of diabetic nephropathy over the last 20 years, patients with type 1 diabetes are at high risk of developing end-stage renal disease (ESRD) and high mortality once ESRD develops. The timing of dialysis initiation has occurred earlier over the years, but a recent study has led to a re-evaluation of that approach. People with type 1 diabetes treated with pre-dialysis (pre-emptive) transplantation have a lower death rate than people with type 1 diabetes treated with dialysis. Living donor kidney transplantation is possible before starting dialysis and is associated with better kidney and patient outcomes as compared to transplantation while on dialysis. Multiple barriers remain that prevent people with type 1 diabetes from enjoying the reduced risk of death afforded by a pre-emptive kidney transplant, including lack of knowledge by primary care physicians, endocrinologists and nephrologists, late referral for transplantation, patient and family misconceptions about timing of transplantation and who can be a donor. New data on both the optimal time to initiate dialysis or to pursue transplantation will be reviewed.
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Affiliation(s)
- M Pavlakis
- Renal Division, The Transplant Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA.
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23
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Patzer RE, McClellan WM. Influence of race, ethnicity and socioeconomic status on kidney disease. Nat Rev Nephrol 2012; 8:533-41. [PMID: 22735764 DOI: 10.1038/nrneph.2012.117] [Citation(s) in RCA: 161] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Low socioeconomic status (SES) influences disease incidence and contributes to poor health outcomes throughout an individual's life course across a wide range of populations. Low SES is associated with increased incidence of chronic kidney disease, progression to end-stage renal disease, inadequate dialysis treatment, reduced access to kidney transplantation, and poor health outcomes. Similarly, racial and ethnic disparities, which in the USA are strongly associated with lower SES, are independently associated with poor health outcomes. In this Review, we discuss individual-level and group-level SES factors, and the concomitant role of race and ethnicity that are associated with and mediate the development of chronic kidney disease, progression to end-stage renal disease and access to treatment.
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Affiliation(s)
- Rachel E Patzer
- Emory University School of Medicine, Department of Surgery, Emory Transplant Center, 101 Woodruff Circle, 5125 WMB, Atlanta, GA 30322, USA
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Clinical features and outcomes of 98 children and adults with dense deposit disease. Pediatr Nephrol 2012; 27:773-81. [PMID: 22105967 PMCID: PMC4423603 DOI: 10.1007/s00467-011-2059-7] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2011] [Revised: 10/12/2011] [Accepted: 10/13/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND Dense deposit disease (DDD) is an ultra-rare renal disease. METHODS In the study reported here, 98 patients and their families participated in a descriptive patient-centered survey using an online research format. Reports were completed by patients (38%) or their parents (62%). Age at diagnosis ranged from 1.9 to 38.9 years (mean 14 years). RESULTS The majority of patients presented with proteinuria and hematuria; 50% had hypertension and edema. Steroids were commonly prescribed, although their use was not evidence-based. One-half of the patients with DDD for 10 years progressed to end-stage renal disease (ESRD), with young females having the greatest risk for renal failure. Of first allografts, 45% failed within 5 years, most frequently due to recurrent disease (70%). Type 1 diabetes (T1D) was present in over 16% of families, which represents a 116-fold increase in incidence compared with the general population (p < 0.001). CONCLUSIONS Based on these findings, we suggest that initiatives are needed to explore the high incidence of T1D in family members of DDD patients and the greater risk for progression to ESRD in young females with DDD. These efforts must be supported by sufficient numbers of patients to establish evidence-based practice guidelines for disease management. An international collaborative research survey should be implemented to encourage broad access and participation.
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Kucirka LM, Grams ME, Balhara KS, Jaar BG, Segev DL. Disparities in provision of transplant information affect access to kidney transplantation. Am J Transplant 2012; 12:351-7. [PMID: 22151011 DOI: 10.1111/j.1600-6143.2011.03865.x] [Citation(s) in RCA: 120] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Recently Centers for Medicare and Medicaid Services (CMS) began asking providers on Form-2728 whether they informed patients about transplantation, and if not, to select a reason. The goals of this study were to describe national transplant education practices and analyze associations between practices and access to transplantation (ATT), based on United States Renal Data System (USRDS) data from 2005 to 2007. Multinomial logistic regression was used to examine factors associated with not being informed about transplantation, and modified Poisson regression to examine associations between not being informed and ATT (all models adjusted for demographics/comorbidities). Of 236,079 incident end-stage renal disease (ESRD) patients, 30.1% were not informed at time of 2728 filing, for reasons reported by providers as follows: 42.1% unassessed, 30.4% medically unfit, 16.9% unsuitable due to age, 3.1% psychologically unfit and 1.5% declined counsel. Older, obese, uninsured, Medicaid-insured and patients at for-profit centers were more likely to be unassessed. Women were more likely to be reported as unsuitable due to age, medically unfit and declined, and African Americans as psychologically unfit. Uninformed patients had a 53% lower rate of ATT, a disparity persisting in the subgroup of uninformed patients who were unassessed. Disparities in ATT may be partially explained by disparities in provision of transplant information; dialysis centers should ensure this critical intervention is offered equitably.
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Affiliation(s)
- L M Kucirka
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Ghahramani N, Karparvar ZY, Ghahramani M, Shrivastava P. Nephrologists' perceptions of renal transplant as treatment of choice for end-stage renal disease, preemptive transplant, and transplanting older patients: an international survey. EXP CLIN TRANSPLANT 2011; 9:223-229. [PMID: 21819365 PMCID: PMC3154028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVES To explore the relation between nephrologists' characteristics and their views of transplant as the treatment of choice for end-stage renal disease, preemptive transplant, and transplant of older patients. MATERIALS AND METHODS A comprehensive international Web-based survey explored the relation between nephrologists' characteristics and their views of transplant as the treatment of choice for end-stage renal disease, preemptive transplant, and transplant of older patients. RESULTS A total of 1448 nephrologists completed the survey. The majority of respondents agreed with transplant as the treatment of choice for end-stage renal disease (75%), preemptive transplant (71%), and transplant for patients > 60 years of age (59%). The likelihood of agreement was higher among transplant and academic nephrologists, and practice at hospitals with ≥ 50 transplants per year. Urban location and ≥ 10 years in practice were associated with higher likelihood of viewing transplant as treatment of choice and favoring preemptive transplant. CONCLUSIONS Demographic and practice characteristics influence nephrologists' attitudes about transplant as the treatment of choice for end-stage renal disease, preemptive transplant, and transplant as an option for older patients. Detailed studies exploring the determinants of nephrologists' attitudes are likely to identify sources of variations in perceptions of patient suitability for transplant. Our findings underscore the need for continuing educational programs addressing evolving aspects of transplant particularly targeting nephrologists practicing within nonacademic centers and in rural areas.
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Abstract
PURPOSE OF REVIEW Preemptive kidney transplant (PKT) is the focus of a new initiative, 'Transplant First'. This initiative focuses on increasing patient transition to transplantation prior to the need for dialysis. This review will evaluate the benefits of PKT and means to accomplish this goal. RECENT FINDINGS Outcomes data show PKT significantly improves long-term survival for the recipient and the allograft. In addition quality of life is improved. This also holds true for children and particularly for adolescents. In 2008, 5.7% of incident patients with end-stage renal disease were placed on the waiting list before beginning dialysis and 0.8% underwent preemptive living donor transplant before wait listing. If patients are evaluated before starting dialysis and are acceptable candidates, up to 40% will receive a preemptive transplant. Recent articles stress that patients want information from their physician; important impediments to PKT remain provider and patient education, insurance coverage and patient reluctance to ask for living donation. SUMMARY Preemptive transplant saves lives. Increased education focused on providers, patients and entire communities is key, as is an increase in living donation. Furthermore, to maximize the impact of transplant first, increased living donor protections and immunosuppression coverage for the life of the allograft are essential.
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Khosla N, Gordon E, Nishi L, Ghossein C. Impact of a chronic kidney disease clinic on preemptive kidney transplantation and transplant wait times. Prog Transplant 2010. [PMID: 20929105 DOI: 10.7182/prtr.20.3.m7233h6k776g8003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Despite the known benefits of preemptive kidney transplantation, its rate of use remains low. OBJECTIVE To determine whether focused, comprehensive education provided at a clinic for patients with chronic kidney disease would improve the rate of preemptive transplantation and transplant wait times. METHODS A retrospective cohort study design was used. The rate of preemptive transplantation and transplant wait times were compared between patients with end-stage renal disease who had been followed in a chronic kidney disease clinic for more than 3 months and patients with end-stage kidney disease who had not been followed for chronic kidney disease care during the same period. RESULTS More African Americans than others had initiated dialysis without having had previous care for chronic kidney disease. The rate of preemptive transplantation was 24% for patients followed in the clinic. For those patients without living donor options, mean transplant referral time was significantly different between patients followed at the clinic and patients who were not: 234 (SD, 392) days before dialysis was started versus 161 (SD, 525) days after dialysis was started (P = .01). CONCLUSION A chronic kidney disease clinic can influence rates of preemptive kidney transplantation and transplantation referral times.
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Majernikova M, Rosenberger J, Prihodova L, Nagyova I, Roland R, van Dijk JP, Groothoff JW. Self-rated health after kidney transplantation and change in graft function. ACTA ACUST UNITED AC 2010. [DOI: 10.1002/dat.20494] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Khosla N, Gordon E, Nishi L, Ghossein C. Impact of a Chronic Kidney Disease Clinic on Preemptive Kidney Transplantation and Transplant Wait Times. Prog Transplant 2010; 20:216-20. [DOI: 10.1177/152692481002000304] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Despite the known benefits of preemptive kidney transplantation, its rate of use remains low. Objective To determine whether focused, comprehensive education provided at a clinic for patients with chronic kidney disease would improve the rate of preemptive transplantation and transplant wait times. Methods A retrospective cohort study design was used. The rate of preemptive transplantation and transplant wait times were compared between patients with end-stage renal disease who had been followed in a chronic kidney disease clinic for more than 3 months and patients with end-stage kidney disease who had not been followed for chronic kidney disease care during the same period. Results More African Americans than others had initiated dialysis without having had previous care for chronic kidney disease. The rate of preemptive transplantation was 24% for patients followed in the clinic. For those patients without living donor options, mean transplant referral time was significantly different between patients followed at the clinic and patients who were not: 234 (SD, 392) days before dialysis was started versus 161 (SD, 525) days after dialysis was started ( P= .01). Conclusion A chronic kidney disease clinic can influence rates of preemptive kidney transplantation and transplantation referral times.
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Kallab S, Bassil N, Esposito L, Cardeau-Desangles I, Rostaing L, Kamar N. Indications for and barriers to preemptive kidney transplantation: a review. Transplant Proc 2010; 42:782-4. [PMID: 20430170 DOI: 10.1016/j.transproceed.2010.02.031] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Preemptive kidney transplantation is the treatment of choice for end-stage renal disease. Compared with nonpreemptive transplantation, preemptive transplantation is significantly associated with improved kidney allograft survival in recipients of either cadaver or living-donor transplants. This seems to be related to better patient survival. It can be proposed to all patients, but still needs to be evaluated for repeat transplantation. The main barriers are organ-allocation policies and late referral of patients to transplantation centers.
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Affiliation(s)
- S Kallab
- Department of Nephrology, Dialysis and Organ Transplantation, INSERM U858, CHU Rangueil, Toulouse, France
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Witczak BJ, Leivestad T, Line PD, Holdaas H, Reisaeter AV, Jenssen TG, Midtvedt K, Bitter J, Hartmann A. Experience From an Active Preemptive Kidney Transplantation Program—809 Cases Revisited. Transplantation 2009; 88:672-7. [DOI: 10.1097/tp.0b013e3181b27b7e] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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