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Shah N, Bennett PN, Cho Y, Leibowitz S, Abra G, Kanjanabuch T, Baharani J. Exploring Preconceptions as Barriers to Peritoneal Dialysis Eligibility: A Global Scenario-Based Survey of Kidney Care Physicians. Kidney Int Rep 2024; 9:941-950. [PMID: 38765569 PMCID: PMC11101779 DOI: 10.1016/j.ekir.2024.01.041] [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: 01/08/2024] [Accepted: 01/22/2024] [Indexed: 05/22/2024] Open
Abstract
Introduction Despite the growing number of patients requiring kidney replacement therapy (KRT), peritoneal dialysis (PD) is underutilized globally. A contributory factor may be clinician myths about its use. The aim of this study was to explore perceptions about PD initiation by clinicians according to various physical, social, and clinical characteristics of patients. Methods An online global survey (in English and Thai) was administered to ascertain nephrologists' and nephrology trainees' decisions on recommending PD as a treatment modality. Results A total of 645 participants (522 nephrologists and 123 trainees; 56% male) from 54 countries (66% from high-income countries [HICs], 22% from upper middle-income countries [UMICs], 12% from lower middle-income countries, and 1% from low-income countries [LICs]) completed the survey. Of the respondents, 81% identified as attending physicians or consultants, and 19% identified as trainees or other. PD was recommended for most scenarios, including repeated exposures to heavy lifting, swimming (especially in a private pool and ocean), among patients with cirrhosis or cognitive impairment with available support, and those living with a pet if a physical separation can be achieved during PD. Certain abdominal surgeries were more acceptable to proceed with PD (hysterectomy, 90%) compared to others (hemicolectomy, 45%). Similar variation was noted for different types of stomas (nephrostomies, 74%; suprapubic catheters, 53%; and ileostomies, 27%). Conclusion The probability of recommending PD in various scenarios was greater among clinicians from HICs, larger units, and consultants with more clinical experience. There is a disparity in recommending PD across various clinical scenarios driven by experience, unit-level characteristics, and region of practice. Globally, evidence-informed education is warranted to rectify misconceptions to enable greater PD uptake.
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Affiliation(s)
- Nikhil Shah
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Paul N. Bennett
- Renal Nursing (Clinical & Health Sciences), University of South Australia, Adelaide, Australia
| | | | | | - Graham Abra
- Satellite Healthcare and Department of Medicine, Division of Nephrology, Stanford University School of Medicine, California, USA
| | - Talerngsak Kanjanabuch
- Division of Nephrology, Department of Medicine and Center of Excellence in Kidney Metabolic Disorders, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Berman ME, Lowentritt JE. Chronic kidney disease and value-based care: Lessons from innovation, iteration, and ideation in primary care. Hemodial Int 2024; 28:6-16. [PMID: 37936554 DOI: 10.1111/hdi.13126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 10/15/2023] [Accepted: 10/16/2023] [Indexed: 11/09/2023]
Abstract
Value-based primary care has reduced health care costs, improved the quality of rendered care, and enhanced the patient experience. Value-based care emphasizes prevention, outreach, follow-up, patient engagement, and comprehensive, whole-person health. Primary care Accountable Care Organizations have leveraged technology-enabled workflows, practice transformation, and cutting-edge data and analytics to achieve success. These efforts are increasingly aided by predictive modeling used in the context of patient identification and prioritization algorithms. Value-based kidney care programs can glean salient takeaways from successful value-based primary care methods and models. The kidney care community is experiencing unprecedented transformation as novel payer programs and financial models burgeon. The authors contend these efforts can be accelerated by the adoption of techniques honed in value-based primary care. To optimize value-based kidney care, though, nephrology thought leaders must transcend the archetype of value-based primary care. To do so, the nephrology community must: (1) impel behavioral change among fee-for-service adherents; (2) harness emerging policy, guidelines, and quality measures; (3) adopt innovative tools, technologies, and therapies. In aggregating lessons from value-based primary care-and leveraging novel methodologies and approaches-the kidney care community will be better equipped to achieve the quadruple aim for kidney care.
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Garg AX, Yohanna S, Naylor KL, McKenzie SQ, Mucsi I, Dixon SN, Luo B, Sontrop JM, Beaucage M, Belenko D, Coghlan C, Cooper R, Elliott L, Getchell L, Heale E, Ki V, Nesrallah G, Patzer RE, Presseau J, Reich M, Treleaven D, Wang C, Waterman AD, Zaltzman J, Blake PG. Effect of a Novel Multicomponent Intervention to Improve Patient Access to Kidney Transplant and Living Kidney Donation: The EnAKT LKD Cluster Randomized Clinical Trial. JAMA Intern Med 2023; 183:1366-1375. [PMID: 37922156 PMCID: PMC10696487 DOI: 10.1001/jamainternmed.2023.5802] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 08/30/2023] [Indexed: 11/05/2023]
Abstract
Importance Patients with advanced chronic kidney disease (CKD) have the best chance for a longer and healthier life if they receive a kidney transplant. However, many barriers prevent patients from receiving a transplant. Objectives To evaluate the effect of a multicomponent intervention designed to target several barriers that prevent eligible patients from completing key steps toward receiving a kidney transplant. Design, Setting, and Participants This pragmatic, 2-arm, parallel-group, open-label, registry-based, superiority, cluster randomized clinical trial included all 26 CKD programs in Ontario, Canada, from November 1, 2017, to December 31, 2021. These programs provide care for patients with advanced CKD (patients approaching the need for dialysis or receiving maintenance dialysis). Interventions Using stratified, covariate-constrained randomization, allocation of the CKD programs at a 1:1 ratio was used to compare the multicomponent intervention vs usual care for 4.2 years. The intervention had 4 main components, (1) administrative support to establish local quality improvement teams; (2) transplant educational resources; (3) an initiative for transplant recipients and living donors to share stories and experiences; and (4) program-level performance reports and oversight by administrative leaders. Main Outcomes and Measures The primary outcome was the rate of steps completed toward receiving a kidney transplant. Each patient could complete up to 4 steps: step 1, referred to a transplant center for evaluation; step 2, had a potential living donor contact a transplant center for evaluation; step 3, added to the deceased donor waitlist; and step 4, received a transplant from a living or deceased donor. Results The 26 CKD programs (13 intervention, 13 usual care) during the trial period included 20 375 potentially transplant-eligible patients with advanced CKD (intervention group [n = 9780 patients], usual-care group [n = 10 595 patients]). Despite evidence of intervention uptake, the step completion rate did not significantly differ between the intervention vs usual-care groups: 5334 vs 5638 steps; 24.8 vs 24.1 steps per 100 patient-years; adjusted hazard ratio, 1.00 (95% CI, 0.87-1.15). Conclusions and Relevance This novel multicomponent intervention did not significantly increase the rate of completed steps toward receiving a kidney transplant. Improving access to transplantation remains a global priority that requires substantial effort. Trial Registration ClinicalTrials.gov Identifier: NCT03329521.
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Affiliation(s)
- Amit X. Garg
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Lawson Health Research Institute and London Health Sciences Centre, London, Ontario, Canada
- ICES, Ontario, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Kidney Patient & Donor Alliance, Canada
- Transplant Ambassador Program, Ontario, Canada
| | - Seychelle Yohanna
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Kyla L. Naylor
- Lawson Health Research Institute and London Health Sciences Centre, London, Ontario, Canada
- ICES, Ontario, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Susan Q. McKenzie
- Kidney Patient & Donor Alliance, Canada
- Transplant Ambassador Program, Ontario, Canada
| | - Istvan Mucsi
- Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Stephanie N. Dixon
- Lawson Health Research Institute and London Health Sciences Centre, London, Ontario, Canada
- ICES, Ontario, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Bin Luo
- Lawson Health Research Institute and London Health Sciences Centre, London, Ontario, Canada
- ICES, Ontario, Canada
| | - Jessica M. Sontrop
- Lawson Health Research Institute and London Health Sciences Centre, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Mary Beaucage
- Patient Governance Circle, Indigenous Peoples Engagement and Research Council and Executive Committee, Can-Solve CKD, Vancouver, British Columbia, Canada
- Provincial Patient and Family Advisory Council, Ontario Renal Network, Toronto, Ontario, Canada
- Patient co-lead Theme 1–Improve a Culture of Donation, Canadian Donation and Transplantation Research Program, Edmonton, Alberta, Canada
| | - Dmitri Belenko
- Division of Nephrology, University of Toronto, Toronto, Ontario, Canada
| | - Candice Coghlan
- Centre for Living Organ Donation, University Health Network, Toronto, Ontario, Canada
| | - Rebecca Cooper
- Ontario Renal Network, Toronto, Ontario, Canada
- Trillium Gift of Life Network, Ontario Health, Toronto, Ontario, Canada
| | - Lori Elliott
- Ontario Renal Network, Ontario Health, Toronto, Ontario, Canada
| | - Leah Getchell
- Lawson Health Research Institute and London Health Sciences Centre, London, Ontario, Canada
- Can-SOLVE CKD Network, Vancouver BC, Canada
| | - Esti Heale
- Ontario Renal Network, Ontario Health, Toronto, Ontario, Canada
| | - Vincent Ki
- Ontario Renal Network, Ontario Health, Toronto, Ontario, Canada
- Trillium Health Partners, Mississauga, Ontario, Canada
| | - Gihad Nesrallah
- Division of Nephrology, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Humber River Regional Hospital, Toronto, Ontario, Canada
| | - Rachel E. Patzer
- Regenstrief Institute, Indianapolis, Indiana
- Department of Surgery, Division of Transplantation, Indiana University School of Medicine, Indianapolis
| | - Justin Presseau
- Clinical Epidemiology Program, Ottawa Health Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ontario, Canada
| | - Marian Reich
- Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease (Can-Solve CKD), Patient Council, Vancouver, British Columbia, Canada
| | - Darin Treleaven
- Trillium Gift of Life Network, Ontario Health, Toronto, Ontario, Canada
- McMaster University, Hamilton, Ontario, Canada
| | - Carol Wang
- Lawson Health Research Institute and London Health Sciences Centre, London, Ontario, Canada
- Division of Nephrology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Department of Research Methods, Evidence and Uptake, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Amy D. Waterman
- Department of Surgery and J.C. Walter Jr. Transplant Center, Houston Methodist Hospital, Houston, Texas
| | - Jeffrey Zaltzman
- Trillium Gift of Life Network, Ontario Health, Toronto, Ontario, Canada
- Division of Nephrology, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Peter G. Blake
- Lawson Health Research Institute and London Health Sciences Centre, London, Ontario, Canada
- Ontario Renal Network, Ontario Health, Toronto, Ontario, Canada
- Division of Nephrology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
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Gordon CE, Adam GP, Jadoul M, Martin P, Balk EM. Kidney Transplantation From Hepatitis C Virus-Infected Donors to Uninfected Recipients: A Systematic Review for the KDIGO 2022 Hepatitis C Clinical Practice Guideline Update. Am J Kidney Dis 2023; 82:410-418. [PMID: 37061019 DOI: 10.1053/j.ajkd.2022.12.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 12/31/2022] [Indexed: 04/17/2023]
Abstract
RATIONALE & OBJECTIVE Direct-acting antiviral (DAA) treatment of hepatitis C virus (HCV) infection in patients with chronic kidney disease (CKD) has made transplantation of kidneys from HCV-infected donors to uninfected recipients (D+/R-) feasible. To facilitate an update to the 2018 KDIGO guideline for patients with CKD and HCV, we conducted a systematic review of HCV D+/R-kidney transplantation coupled with DAA treatment. STUDY DESIGN Systematic review and meta-analysis. SETTING & STUDY POPULATIONS We included studies of HCV D+/R-kidney transplantations that used any DAA protocol. SELECTION CRITERIA FOR STUDIES Based on a search of PubMed, Embase, Cochrane, CINAHL, and ClinicalTrials.gov through February 1, 2022, conferences from 2019 to 2021, and the 2018 KDIGO HCV guideline we identified single-group (D+/R-) or comparative studies of D+/R-versus D-/R-kidney transplantation. DATA EXTRACTION Conducted in SRDR-Plus with review by a second researcher. ANALYTICAL APPROACH Maximum likelihood meta-analyses; the certainty of evidence was assessed per GRADE (Grading of Recommendations Assessment, Development and Evaluation). RESULTS We identified 16 studies (N=557). A sustained viral response at 12 weeks after treatment (SVR12) was observed in 97.7% (95% CI, 96.3%-98.8%). Ultrashort duration treatment (≤8 days) resulted in viremia requiring standard-course DAA treatment in some patients, all of whom achieved SVR12 after 1 or rarely 2 DAA courses. Serious adverse events from DAA treatment were rare after D+/R-transplantation (0.4% [95% CI, 0.1%-2.8%]). At≥1 year after D+/R-transplantation, recipient death occurred in 2.1% (95% CI, 0.9-3.7) and allograft survival was 97.6% (95% CI, 95.7%-98.9%). Estimated glomerular filtration rate 1 year after transplantation ranged from 46 to 74mL/min/1.73m2. LIMITATIONS Analyses were generally based on low-certainty evidence. Uncertainty exists about the long-term safety and efficacy of D+/R-transplantation. Few studies investigated ultrashort treatment courses. CONCLUSIONS Kidney transplantation from HCV-infected donors to uninfected recipients followed by DAA treatment appears to be safe and associated with excellent 1-year clinical outcomes. PLAIN-LANGUAGE SUMMARY Due to the high efficacy of direct-acting antivirals (DAA), the use of kidneys from HCV-infected deceased donors may increase rates of kidney transplantation. We conducted a systematic review for the 2022 KDIGO Clinical Practice Guideline on Hepatitis C to evaluate the safety and efficacy of kidney transplantation from HCV-infected donors to uninfected recipients (D+/R-) followed by DAA therapy. Sixteen studies comprising 557 patients revealed high rates of sustained viral response, low rates of adverse events, and excellent patient and allograft survival 1 year after transplantation. Kidney transplantation from HCV-infected deceased donors to uninfected recipients treated with DAA appears safe and effective. Future studies should investigate shorter treatment durations, monitor safety, and obtain longer-term efficacy data.
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Affiliation(s)
- Craig E Gordon
- Division of Nephrology, Department of Medicine, School of Medicine, Tufts University, Boston, Massachusetts.
| | - Gaelen P Adam
- Brown Center for Evidence Synthesis in Health, Brown School of Public Health, Brown University, Providence, Rhode Island
| | - Michel Jadoul
- Department of Nephrology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Paul Martin
- Division of Digestive Health and Liver Diseases, School of Medicine, University of Miami, Miami, Florida
| | - Ethan M Balk
- Brown Center for Evidence Synthesis in Health, Brown School of Public Health, Brown University, Providence, Rhode Island
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Reaven NL, Funk SE, Mathur V, Ferguson TW, Lai J, Tangri N. Association of the Kidney Failure Risk Equation With High Health Care Costs. Kidney Int Rep 2023. [DOI: 10.1016/j.ekir.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
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Lim K, Chen N, Hato T. Klotho in Kidney Transplantation: A New and Important Target? Transplantation 2023; 107:580-581. [PMID: 36253902 PMCID: PMC9974534 DOI: 10.1097/tp.0000000000004332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Kenneth Lim
- Division of Nephrology & Hypertension, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Neal Chen
- Division of Nephrology & Hypertension, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Takashi Hato
- Division of Nephrology & Hypertension, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
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Fleetwood VA, Caliskan Y, Rub FAA, Axelrod D, Lentine KL. Maximizing opportunities for kidney transplantation in older adults. Curr Opin Nephrol Hypertens 2023; 32:204-211. [PMID: 36633323 DOI: 10.1097/mnh.0000000000000871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE OF REVIEW To summarize the current state of evidence related to the outcomes of older adults who need and receive kidney transplants, and strategies to facilitate appropriate transplant access in this at-risk group. RECENT FINDINGS Older adults are a rapidly growing subgroup of the kidney transplant waitlist. Compared to younger adults, older kidney transplant recipients have increased mortality after kidney transplant and lower death-censored graft survival. In determining suitability for transplantation in older patients, clinicians must balance procedural and immunosuppression-related risk with incremental survival when compared with dialysis. To appropriately increase access to transplantation in this population, clinicians and policy makers consider candidates' chronological age and frailty, as well as the quality of and waiting time for a donated allograft. Given risk of deterioration prior to transplant, candidates should be rapidly evaluated, listed, and transplanted using living donor and or less than ideal deceased donor organs when available. SUMMARY Access to transplantation for older adults can be increased through targeted interventions to address frailty and reduce waiting times through optimized organ use. Focused study and educational interventions for patients and providers are needed to improve the outcomes of this vulnerable group.
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Affiliation(s)
- Vidya A Fleetwood
- Saint Louis University Center for Abdominal Transplantation, SSM-Saint Louis University Hospital
| | - Yasar Caliskan
- Saint Louis University Center for Abdominal Transplantation, SSM-Saint Louis University Hospital
| | - Fadee Abu Al Rub
- Saint Louis University Center for Abdominal Transplantation, SSM-Saint Louis University Hospital
| | | | - Krista L Lentine
- Saint Louis University Center for Abdominal Transplantation, SSM-Saint Louis University Hospital
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Killian AC, Reed RD, McLeod MC, MacLennan PA, Kumar V, Pittman SE, Maynor AG, Stanford LA, Baker GA, Schinstock CA, Silkensen JR, Roll GR, Segev DL, Orandi BJ, Lewis CE, Locke JE. Diabetes-free survival among living kidney donors and non-donors with obesity: A longitudinal cohort study. PLoS One 2022; 17:e0276882. [PMID: 36399462 PMCID: PMC9674148 DOI: 10.1371/journal.pone.0276882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 10/13/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Approval of living kidney donors (LKD) with end-stage kidney disease (ESKD) risk factors, such as obesity, has increased. While lifetime ESKD development data are lacking, the study of intermediate outcomes such as diabetes is critical for LKD safety. Donation-attributable diabetes risk among persons with obesity remains unknown. The purpose of this study was to evaluate 10-year diabetes-free survival among LKDs and non-donors with obesity. METHODS This longitudinal cohort study identified adult, LKDs (1976-2020) from 42 US transplant centers and non-donors from the Coronary Artery Risk Development in Young Adults (1985-1986) and the Atherosclerosis Risk in Communities (1987-1989) studies with body mass index ≥30 kg/m2. LKDs were matched to non-donors on baseline characteristics (age, sex, race, body mass index, systolic and diastolic blood pressure) plus diabetes-specific risk factors (family history of diabetes, impaired fasting glucose, smoking history). Accelerated failure time models were utilized to evaluate 10-year diabetes-free survival. FINDINGS Among 3464 participants, 1119 (32%) were LKDs and 2345 (68%) were non-donors. After matching on baseline characteristics plus diabetes-specific risk factors, 4% (7/165) LKDs and 9% (15/165) non-donors developed diabetes (median follow-up time 8.5 (IQR: 5.6-10.0) and 9.1 (IQR: 5.9-10.0) years, respectively). While not significant, LKDs were estimated to live diabetes-free 2 times longer than non-donors (estimate 1.91; 95% CI: 0.79-4.64, p = 0.15). CONCLUSIONS LKDs with obesity trended toward living longer diabetes-free than non-donors with obesity, suggesting within the decade following donation there was no increased diabetes risk among LKDs. Further work is needed to evaluate donation-attributable diabetes risk long-term.
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Affiliation(s)
- A. Cozette Killian
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Rhiannon D. Reed
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - M. Chandler McLeod
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Paul A. MacLennan
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Vineeta Kumar
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Sydney E. Pittman
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Andrew G. Maynor
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Luke A. Stanford
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Gavin A. Baker
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Carrie A. Schinstock
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, United States of America
| | - John R. Silkensen
- Department of Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, United States of America
| | - Garrett R. Roll
- Division of Transplant, Department of Surgery, University of California San Francisco, San Francisco, CA, United States of America
| | - Dorry L. Segev
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, United States of America
| | - Babak J. Orandi
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Cora E. Lewis
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Jayme E. Locke
- Comprehensive Transplant Institute, University of Alabama at Birmingham, Birmingham, AL, United States of America
- * E-mail:
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Managing the Costs of Routine Follow-up Care After Living Kidney Donation: a Review and Survey of Contemporary Experience, Practices, and Challenges. CURRENT TRANSPLANTATION REPORTS 2022; 9:328-335. [PMID: 36187071 PMCID: PMC9510404 DOI: 10.1007/s40472-022-00379-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2022] [Indexed: 11/12/2022]
Abstract
Purpose of Review While living organ donor follow-up is mandated for 2 years in the USA, formal guidance on recovering associated costs of follow-up care is lacking. In this review, we discuss current billing practices of transplant programs for living kidney donor follow-up, and propose future directions for managing follow-up costs and supporting cost neutrality in donor care. Recent Findings Living donors may incur costs and financial risks in the donation process, including travel, lost time from work, and dependent care. In addition, adherence to the Organ Procurement and Transplantation Network (OPTN) mandate for US transplant programs to submit 6-, 12-, and 24-month postdonation follow-up data to the national registry may incur out-of-pocket medical costs for donors. Notably, the Centers for Medicare and Medicaid Services (CMS) has explicitly disallowed transplant programs to bill routine, mandated follow-up costs to the organ acquisition cost center or to the recipient’s Medicare insurance. We conducted a survey of transplant staff in the USA (distributed October 22, 2020–March 15, 2021), which identified that the mechanisms for recovering or covering the costs of mandated routine postdonation follow-up at responding programs commonly include billing recipients’ private insurance (40%), while 41% bill recipients’ Medicare insurance. Many programs reported utilizing institutional allowancing (up to 50%), and some programs billed the organ acquisition cost center (25%). A small percentage (11%) reported billing donors or donors’ insurance. Summary To maintain a high level of adherence to living donor follow-up without financially burdening donors, up-to-date resources are needed on handling routine donor follow-up costs in ways that are policy-compliant and effective for donors and programs. Development of a government-supported national living donor follow-up registry like the Living Donor Collective may provide solutions for aspects of postdonation follow-up, but requires transplant program commitment to register donors and donor candidates as well as donor engagement with follow-up outreach contacts after donation.
Supplementary Information The online version contains supplementary material available at 10.1007/s40472-022-00379-w.
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Manns BJ, Garg AX, Sood MM, Ferguson T, Kim SJ, Naimark D, Nesrallah GE, Soroka SD, Beaulieu M, Dixon SN, Alam A, Allu S, Tangri N. Multifaceted Intervention to Increase the Use of Home Dialysis: A Cluster Randomized Controlled Trial. Clin J Am Soc Nephrol 2022; 17:535-545. [PMID: 35314481 PMCID: PMC8993468 DOI: 10.2215/cjn.13191021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 02/03/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND OBJECTIVES Home dialysis therapies (peritoneal and home hemodialysis) are less expensive and provide similar outcomes to in-center hemodialysis, but they are underutilized in most health systems. Given this, we designed a multifaceted intervention to increase the use of home dialysis. In this study, our objective was to evaluate the effect of this intervention on home dialysis use in CKD clinics across Canada. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a cluster randomized controlled trial in 55 CKD clinic clusters in nine provinces in Canada between October 2014 and November 2015. Participants included all adult patients who initiated dialysis in the year following the intervention. We evaluated the implementation of a four-component intervention, which included phone surveys from a knowledge translation broker, a 1-year center-specific audit/feedback on home dialysis use, delivery of an educational package (including tools aimed at both providers and patients), and an academic detailing visit. The primary outcome was the proportion of patients using home dialysis at 180 days after dialysis initiation. RESULTS A total of 55 clinics were randomized (27 in the intervention and 28 in the control), with 5312 patients initiating dialysis in the 1-year follow-up period. In the primary analysis, there was no difference in the use of home dialysis at 180 days in the intervention and control clusters (absolute risk difference, 4%; 95% confidence interval, -2% to 10%). Using a difference-in-difference comparison, the use of home dialysis at 180 days was similar before and after implementation of the intervention (difference of 0% in intervention clinics; 95% confidence interval, -2% to 3%; difference of 0.8% in control clinics; 95% confidence interval, -1% to 3%; P=0.84). CONCLUSIONS A multifaceted intervention did not increase the use of home dialysis in adults initiating dialysis. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER A Cluster Randomized Trial to Assess the Impact of Patient and Provider Education on Use of Home Dialysis, NCT02202018.
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Affiliation(s)
- Braden J Manns
- Department of Medicine and Community Health Sciences, Libin Cardiovascular Institute and O'Brien Public Health Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Amit X Garg
- Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Manish M Sood
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Thomas Ferguson
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - S Joseph Kim
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Department of Medicine, Division of Nephrology, University of Toronto, Toronto, Ontario, Canada
| | - David Naimark
- Division of Nephrology, Sunnybrook and Women's College Health Sciences Centre, Toronto, Ontario, Canada
| | - Gihad E Nesrallah
- Li Ka Shing Knowledge Institute, Keenan Research Centre, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Steven D Soroka
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Monica Beaulieu
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Stephanie N Dixon
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Ahsan Alam
- Division of Nephrology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Selina Allu
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Navdeep Tangri
- Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.,Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada
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11
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Lentine KL, Mannon RB, Mandelbrot D. Understanding and Overcoming Financial Risks for Living Organ Donors. Am J Kidney Dis 2021; 79:159-161. [PMID: 34872794 DOI: 10.1053/j.ajkd.2021.09.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 09/09/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Krista L Lentine
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, Missouri.
| | - Roslyn B Mannon
- Division of Nephrology, Department of Medicine, University of Nebraska, Omaha, Nebraska
| | - Didier Mandelbrot
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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12
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Jain G, Weiner DE. Value-Based Care in Nephrology: The Kidney Care Choices Model and Other Reforms. KIDNEY360 2021; 2:1677-1683. [PMID: 35372980 PMCID: PMC8785791 DOI: 10.34067/kid.0004552021] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 08/13/2021] [Indexed: 02/04/2023]
Abstract
The Advancing American Kidney Health (AAKH) initiative has reinvigorated the focus on improving the care of patients with advanced CKD. Multiple interventions have been planned, focusing on education campaigns for both clinicians and patients, delaying the progression of kidney disease and improving utilization of home dialysis modalities and kidney transplantation. Value-based care models for patients with advanced kidney disease are being rolled out, with the ESKD treatment choices model starting in January 2021, and the Kidney Care Choices model planned to start in January 2022. There is increasing emphasis on the role of the nephrologist as the "captain of the ship," leading efforts in care coordination as physician leaders. The transplant reforms have focused on changes to organ procurement organizations aiming to increase availability of organs, and transplants performed, both deceased and living donor, and removing financial disincentives from live organ donation. The American Society of Nephrology (ASN) and the National Kidney Foundation (NKF) are partnering with the Department of Health and Human Services to develop educational material for clinicians and patients. In this review, we discuss these reforms, potential challenges that have arisen, and potential solutions, with emphasis on the Kidney Care Choices model.
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Affiliation(s)
- Gaurav Jain
- Division of Nephrology, Department of Medicine, University of Alabama in Birmingham, Birmingham, Alabama
| | - Daniel E. Weiner
- Department of Nephrology, Tufts Medical Center, Boston, Massachusetts
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13
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Lentine KL, Pastan S, Mohan S, Reese PP, Leichtman A, Delmonico FL, Danovitch GM, Larsen CP, Harshman L, Wiseman A, Kramer HJ, Vassalotti J, Joseph J, Longino K, Cooper M, Axelrod DA. A Roadmap for Innovation to Advance Transplant Access and Outcomes: A Position Statement From the National Kidney Foundation. Am J Kidney Dis 2021; 78:319-332. [PMID: 34330526 DOI: 10.1053/j.ajkd.2021.05.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 05/01/2021] [Indexed: 02/07/2023]
Abstract
Over the past 65 years, kidney transplantation has evolved into the optimal treatment for patients with kidney failure, dramatically reducing suffering through improved survival and quality of life. However, access to transplant is still limited by organ supply, opportunities for transplant are inequitably distributed, and lifelong transplant survival remains elusive. To address these persistent needs, the National Kidney Foundation convened an expert panel to define an agenda for future research. The key priorities identified by the panel center on the needs to develop and evaluate strategies to expand living donation, improve waitlist management and transplant readiness, maximize use of available deceased donor organs, and extend allograft longevity. Strategies targeting the critical goal of decreasing organ discard that warrant research investment include educating patients and clinicians about potential benefits of accepting nonstandard organs, use of novel organ assessment technologies and real-time decision support, and approaches to preserve and resuscitate allografts before implantation. The development of personalized strategies to reduce the burden of lifelong immunosuppression and support "one transplant for life" was also identified as a vital priority. The panel noted the specific goal of improving transplant access and graft survival for children with kidney failure. This ambitious agenda will focus research investment to promote greater equity and efficiency in access to transplantation, and help sustain long-term benefits of the gift of life for more patients in need.
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Affiliation(s)
- Krista L Lentine
- Saint Louis University Center for Abdominal Transplantation, St Louis, MO.
| | - Stephen Pastan
- Department of Medicine, Emory Transplant Center, Atlanta, GA
| | - Sumit Mohan
- Department of Medicine, Columbia University Medical Center, New York, NY
| | - Peter P Reese
- Renal-Electrolyte and Hypertension Division, University of Pennsylvania, Philadelphia, PA
| | - Alan Leichtman
- Department of Medicine, University of Michigan, Ann Arbor, MI
| | | | | | | | - Lyndsay Harshman
- Department of Pediatrics, University of Iowa Transplant Institute, Iowa City, IA
| | - Alexander Wiseman
- Department of Medicine, Centura Health-Porter Adventist Hospital, Aurora, CO
| | | | - Joseph Vassalotti
- National Kidney Foundation, New York, NY; Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | | | - Matthew Cooper
- Department of Surgery, Medstar Georgetown Transplant Institute, Washington, DC
| | - David A Axelrod
- Department of Surgery, University of Iowa Transplant Institute, Iowa City, IA
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14
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Yohanna S, Naylor KL, Mucsi I, McKenzie S, Belenko D, Blake PG, Coghlan C, Dixon SN, Elliott L, Getchell L, Ki V, Nesrallah G, Patzer RE, Presseau J, Reich M, Sontrop JM, Treleaven D, Waterman AD, Zaltzman J, Garg AX. A Quality Improvement Intervention to Enhance Access to Kidney Transplantation and Living Kidney Donation (EnAKT LKD) in Patients With Chronic Kidney Disease: Clinical Research Protocol of a Cluster-Randomized Clinical Trial. Can J Kidney Health Dis 2021; 8:2054358121997266. [PMID: 33948191 PMCID: PMC8054216 DOI: 10.1177/2054358121997266] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Indexed: 12/31/2022] Open
Abstract
Background: Many patients with kidney failure will live longer and healthier lives if
they receive a kidney transplant rather than dialysis. However, multiple
barriers prevent patients from accessing this treatment option. Objective: To determine if a quality improvement intervention provided in chronic kidney
disease (CKD) programs (vs. usual care) enables more patients with no
recorded contraindications to kidney transplant to complete more steps
toward receiving a kidney transplant. Design: This protocol describes a pragmatic 2-arm, parallel-group, open-label,
registry-based, cluster-randomized clinical trial—the Enhance Access to
Kidney Transplantation and Living Kidney Donation (EnAKT LKD) trial. Setting: All 26 CKD programs in Ontario, Canada, with a trial start date of November
1, 2017. The original end date of March 31, 2021 (3.4 years) has been
extended to December 31, 2021 (4.1 years) due to the COVID-19 pandemic. Participants: During the trial, the 26 CKD programs are expected to care for more than 10
000 adult patients with CKD (including patients approaching the need for
dialysis and patients receiving dialysis) with no recorded contraindications
to a kidney transplant. Intervention: Programs were randomly allocated to provide a quality improvement
intervention or usual care. The intervention has 4 main components: (1)
local quality improvement teams and administrative support; (2) tailored
education and resources for staff, patients, and living kidney donor
candidates; (3) support from kidney transplant recipients and living kidney
donors; and (4) program-level performance reports and oversight by program
leaders. Primary Outcome: The primary outcome is the number of key steps completed toward receiving a
kidney transplant analyzed at the cluster level (CKD program). The following
4 unique steps per patient will be counted: (1) patient referred to a
transplant center for evaluation, (2) at least one living kidney donor
candidate contacts a transplant center for an intended recipient and
completes a health history questionnaire to begin their evaluation, (3)
patient added to the deceased donor transplant wait list, and (4) patient
receives a kidney transplant from a living or deceased donor. Planned Primary Analysis: Study data will be obtained from Ontario’s linked administrative healthcare
databases. An intent-to-treat analysis will be conducted comparing the
primary outcome between randomized groups using a 2-stage approach. First
stage: residuals are obtained from fitting a regression model to
individual-level variables ignoring intervention and clustering effects.
Second stage: residuals from the first stage are aggregated at the cluster
level as the outcome. Limitations: It may not be possible to isolate independent effects of each intervention
component, the usual care group could adopt intervention components leading
to contamination bias, and the relatively small number of clusters could
mean the 2 arms are not balanced on all baseline prognostic factors. Conclusions: The EnAKT LKD trial will provide high-quality evidence on whether a
multi-component quality improvement intervention helps patients complete
more steps toward receiving a kidney transplant. Trial registration: Clinicaltrials.gov; identifier: NCT03329521.
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Affiliation(s)
| | - Kyla L Naylor
- ICES, ON, Canada.,Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Istvan Mucsi
- Division of Nephrology, University of Toronto, ON, Canada
| | | | - Dmitri Belenko
- Division of Nephrology, University of Toronto, ON, Canada
| | - Peter G Blake
- Division of Nephrology, Western University, London, ON, Canada.,Ontario Renal Network, Ontario Health, Toronto, Canada
| | | | - Stephanie N Dixon
- ICES, ON, Canada.,Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Lori Elliott
- Ontario Renal Network, Ontario Health, Toronto, Canada
| | - Leah Getchell
- Division of Nephrology, London Health Sciences Centre, ON, Canada
| | - Vincent Ki
- Ontario Renal Network, Ontario Health, Toronto, Canada.,Trillium Health Partners, Mississauga, ON, Canada
| | - Gihad Nesrallah
- Ontario Renal Network, Ontario Health, Toronto, Canada.,Humber River Regional Hospital, Toronto, ON, Canada
| | - Rachel E Patzer
- Health Services Research Center, Emory University School of Medicine, Atlanta, GA, USA
| | - Justin Presseau
- Clinical Epidemiology Program, Ottawa Health Research Institute, ON, Canada
| | - Marian Reich
- Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease, Patient Council, Vancouver, BC, Canada
| | - Jessica M Sontrop
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada.,Division of Nephrology, London Health Sciences Centre, ON, Canada
| | - Darin Treleaven
- Division of Nephrology, McMaster University, Hamilton, ON, Canada.,Trillium Gift of Life Network, Toronto, ON, Canada
| | - Amy D Waterman
- Division of Nephrology, University of California, Los Angeles, USA
| | - Jeffrey Zaltzman
- Trillium Gift of Life Network, Toronto, ON, Canada.,Division of Nephrology, St. Michael's Hospital, Toronto, ON, Canada
| | - Amit X Garg
- ICES, ON, Canada.,Department of Epidemiology and Biostatistics, Western University, London, ON, Canada.,Division of Nephrology, Western University, London, ON, Canada.,Ontario Renal Network, Ontario Health, Toronto, Canada
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15
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Abstract
The United States has faced an unprecedented opioid crisis in recent years, which has led to an increase in opioid overdose-related deaths and, consequently, an increase in the number of potential deceased donors available for transplantation. This new pool of potential organ donors is composed of younger donors with higher infectious disease transmission risk. The use of organs from these donors requires appropriate patient education, informed consent, and post-transplant monitoring practices. Prescription opioid use is also an important component of the evaluation of transplant and living donor candidates because it may impact outcomes and eligibility for the procedures. In kidney transplant recipients, prescription opioid use predicts a higher risk of mortality, graft loss, and post-transplant complications. These effects seem to be proportional to the levels of opioid use, and to parallel patterns in other transplant populations such as liver, heart and lung recipients. Among living kidney donors, predonation prescription opioid use is associated with an increased risk of re-admission after nephrectomy. Overall, the opioid epidemic creates educational needs for patients awaiting deceased donor transplant, and also impacts the evaluation and care of transplant candidates. Among transplant candidates and recipients, the identification of patients with chronic opioid use should prompt multidisciplinary evaluation and management strategies to minimize risks.
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Affiliation(s)
- Marie-Camille Lafargue
- Transplantation Research Center, Renal Division, Brigham & Women’s Hospital, Harvard Medical School, Boston, MA
| | - Yasar Caliskan
- Saint Louis University Center for Abdominal Transplantation, St. Louis, Missouri
| | - Krista L Lentine
- Saint Louis University Center for Abdominal Transplantation, St. Louis, Missouri
| | - Leonardo V. Riella
- Transplantation Research Center, Renal Division, Brigham & Women’s Hospital, Harvard Medical School, Boston, MA
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16
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Heher EC, Hricik DE, Brennan DC. Securing the future of kidney transplantation by addressing the challenges of transplant nephrology. Am J Transplant 2021; 21:37-43. [PMID: 33405318 DOI: 10.1111/ajt.16264] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 07/21/2020] [Accepted: 08/09/2020] [Indexed: 01/25/2023]
Abstract
Kidney transplant is a life-changing procedure, and transplant nephrologists, as part of a larger transplant team, play an important role in the field by managing the complex medical needs of transplant patients. The subspecialty of transplant nephrology, however, faces structural challenges related to its workforce, reporting structures, compensation, research and innovation, and health care information technology. The position of transplant nephrology at the academic and operational intersection of medicine and surgery may limit its access to critical resources, hinder academic promotion, and contribute to physician burnout. The authors provide an overview of the subspecialty transplant nephrology and propose solutions. Collaborative efforts that fortify the subspecialty of transplant nephrology will ultimately improve the lives of patients suffering from kidney disease.
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Affiliation(s)
- Eliot C Heher
- Square Knot Health, Inc., Newton, Massachusetts, USA
| | - Donald E Hricik
- Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Daniel C Brennan
- Nephrology Division and Comprehensive Transplant Center, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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17
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Watford DJ, Cheng XS, Han J, Stedman MR, Chertow GM, Tan JC. Toward telemedicine-compatible physical functioning assessments in kidney transplant candidates. Clin Transplant 2020; 35:e14173. [PMID: 33247983 PMCID: PMC7906942 DOI: 10.1111/ctr.14173] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 11/15/2020] [Accepted: 11/18/2020] [Indexed: 12/15/2022]
Abstract
Frailty is associated with adverse kidney transplant outcomes and can be assessed by subjective and objective metrics. There is increasing recognition of the value of metrics obtainable remotely. We compared the self‐reported SF‐36 physical functioning subscale score (SF‐36 PF) with in‐person physical performance tests (6‐min walk and sit‐to‐stand) in a prospective cohort of kidney transplant candidates. We assessed each metric's ability to predict time to the composite outcome of waitlist removal or death, censoring at transplant. We built time‐dependent receiver operating characteristic curves and calculated the area under the curve [AUC(t)] at 1 year, using bootstrapping for internal validation. In 199 patients followed for a median of 346 days, 41 reached the composite endpoint. Lower SF‐36 PF scores were associated with higher risk of waitlist removal/death, with every 10‐point decrease corresponding to a 16% increase in risk. All models showed an AUC(t) of 0.83–0.84 that did not contract substantially after internal validation. Among kidney transplant candidates, SF‐36 PF, obtainable remotely, can help to stratify the risk of waitlist removal or death, and may be used as a screening tool for poor physical functioning in ongoing candidate evaluation, particularly where travel, increasing patient volume, or other restrictions challenge in‐person assessment.
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Affiliation(s)
- Daniel J Watford
- Division of Nephrology, Department of Medicine, Stanford University Medical Center, Palo Alto, CA, USA
| | - Xingxing S Cheng
- Division of Nephrology, Department of Medicine, Stanford University Medical Center, Palo Alto, CA, USA
| | - Jialin Han
- Division of Nephrology, Department of Medicine, Stanford University Medical Center, Palo Alto, CA, USA
| | - Margaret R Stedman
- Division of Nephrology, Department of Medicine, Stanford University Medical Center, Palo Alto, CA, USA
| | - Glenn M Chertow
- Division of Nephrology, Department of Medicine, Stanford University Medical Center, Palo Alto, CA, USA
| | - Jane C Tan
- Division of Nephrology, Department of Medicine, Stanford University Medical Center, Palo Alto, CA, USA
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18
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Integrated Risk Assessment Versus Age-Specific GFR Thresholds for Living Donor Candidate Evaluation. Transplantation 2020; 104:2464-2466. [DOI: 10.1097/tp.0000000000003243] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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