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Chapman JR. Cancer Surveillance After Transplantation: An Evidence-free Zone? Transplantation 2024:00007890-990000000-00764. [PMID: 38771098 DOI: 10.1097/tp.0000000000005060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
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Nankivell BJ, Chapman JR. Histology versus molecular surveillance: claims and evidence. Kidney Int 2023; 104:428-432. [PMID: 37599017 DOI: 10.1016/j.kint.2022.06.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 06/07/2022] [Accepted: 06/16/2022] [Indexed: 08/22/2023]
Affiliation(s)
| | - Jeremy R Chapman
- Department of Renal Medicine, Westmead Hospital, Sydney, Australia
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3
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Au EHK, Chapman JR, Teixeira-Pinto A, Craig JC, Wong G. Variations in Risk of Cancer and Death From Cancer According to Kidney Allograft Function, Graft Loss, and Return to Dialysis. Transplantation 2023; 107:1359-1364. [PMID: 36683232 DOI: 10.1097/tp.0000000000004493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Cancer incidence and mortality may change with varying kidney allograft function and after graft loss. We aimed to quantify cancer incidence and mortality during periods with a functioning graft and after graft loss. METHODS We included all adult Australians aged 20 and above who commenced kidney replacement therapy between 1982 and 2014 using data from Australia and New Zealand Dialysis and Transplant Registry. We calculated the standardized incidence ratios and standardized mortality ratios (standardized against the Australian general population) for dialysis patients and transplant recipients during periods with a functioning graft and after graft loss. RESULTS A total of 44 765 dialysis patients without transplants, 13 443 with first kidney transplants, 2951 after first graft loss, 1010 with second transplants, and 279 after second graft loss were followed for 274 660 patient-years. Cancer incidence and mortality (per 100 000 patient-years) were 1564 and 760 in dialysis patients, 1564 and 689 in recipients of first transplants, 1188 and 390 after first graft loss, 1525 and 693 after second transplants, and 1645 and 779 after second graft loss. Cancer standardized incidence ratios and standardized mortality ratios (95% confidence intervals) were 1.15 (1.11-1.20) and 1.29 (1.21-1.36) for dialysis patients, 2.03 (1.94-2.13) and 2.50 (2.33-2.69) for recipients following their first transplant, 1.55 (1.29-1.85) and 1.40 (1.00-1.90) after first graft loss, 2.18 (1.79-2.63) and 3.00 (2.23-3.96) for second transplants, 2.59 (1.56-4.04) and 3.82 (1.75-7.25) after second graft loss. CONCLUSIONS In kidney transplant recipients, cancer incidence and mortality are highest during periods with a functioning graft and remained higher than in the general population even after graft loss.
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Affiliation(s)
- Eric H K Au
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
- Centre for Transplant and Renal Research, Westmead Hospital, Sydney, NSW, Australia
- School of Public Health, Faculty of Medicine, University of Sydney, Sydney, NSW, Australia
| | - Jeremy R Chapman
- Centre for Transplant and Renal Research, Westmead Hospital, Sydney, NSW, Australia
| | - Armando Teixeira-Pinto
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
- School of Public Health, Faculty of Medicine, University of Sydney, Sydney, NSW, Australia
| | - Jonathan C Craig
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Germaine Wong
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
- Centre for Transplant and Renal Research, Westmead Hospital, Sydney, NSW, Australia
- School of Public Health, Faculty of Medicine, University of Sydney, Sydney, NSW, Australia
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Geissler EK, Kirste G, Meade MO, Chapman JR. Establishing Guidelines for Organ Donation Systems. Transplant Direct 2023; 9:e1481. [PMID: 37138557 PMCID: PMC10150915 DOI: 10.1097/txd.0000000000001481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 03/16/2023] [Indexed: 05/05/2023] Open
Affiliation(s)
- Edward K. Geissler
- Department of Surgery, University Hospital Regensburg, University of Regensburg, Regensburg, Germany
| | - Günter Kirste
- Department of Surgery, University Hospital of Freiburg, Albert Ludwig University of Freiburg, Freiburg im Breisgau, Germany
| | - Maureen O. Meade
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
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Chapman JR. Dying of Cancer With Kidney Disease. Am J Kidney Dis 2022; 80:429-430. [PMID: 35927138 DOI: 10.1053/j.ajkd.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 05/18/2022] [Indexed: 01/29/2023]
Affiliation(s)
- Jeremy R Chapman
- Western Clinical School, University of Sydney, Sydney, New South Wales, Australia.
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Dansie KB, Davies CE, Morton RL, Hawley CM, Johnson DW, Craig JC, Chapman JR, Cooper BA, Pollock CA, Harris DCH, McDonald SP. The IDEAL trial in Australia and New Zealand: Clinical and Economic impact. Nephrol Dial Transplant 2021; 37:168-174. [PMID: 34581810 DOI: 10.1093/ndt/gfab270] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The impact of research findings on clinical practice usually remains uncertain and unmeasured. To address this problem, we examined the long term clinical and economic impact of the Initiating Dialysis Early and Late (IDEAL) study, using data from the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry. METHODS We performed a registry-based study including all incident adult dialysis patients in Australia and New Zealand from July 2000-June 2018. A piecewise-linear regression model was used to examine differences in mean estimated Glomerular Filtration Rate (eGFR) at dialysis commencement for the years prior (2000-2010) and following (2010-2018) publication of the IDEAL results. The Return on Investment (ROI) was calculated using the total cost of performing the IDEAL study and the cost or savings accruing in Australia and New Zealand from change in dialysis initiation practice. RESULTS From July 2000-June 2010, mean eGFR at dialysis commencement increased at a rate of 0.21 mL/min/1.73m2 per year (95% CI 0.19 to 0.23). After IDEAL results were published, mean eGFR at dialysis commencement did not show any temporal change (-0.01 mL/min/1.73m2 per year, 95% CI -0.03 to 0.01). The ROI of the IDEAL study was AUD $35.70 per AUD $1 spent, an estimated saving to Australian and New Zealand health systems of up to AUD $84M per year. CONCLUSIONS The previous trend to higher eGFR at dialysis commencement changed following publication of IDEAL results to a steady eGFR which has continued for a decade, avoiding unnecessary dialysis treatments and accruing savings to Australian and New Zealand health systems.
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Affiliation(s)
- Kathryn B Dansie
- Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australian Health and Medical Research Institute, South Australia, Australia
| | - Christopher E Davies
- Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australian Health and Medical Research Institute, South Australia, Australia.,Adelaide Medical School, University of Adelaide, South Australia, Australia
| | - Rachael L Morton
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, New South Wales, Australia
| | - Carmel M Hawley
- Department of Nephrology, Princess Alexandra Hospital, Queensland, Australia.,Australasian Kidney Trials Network, University of Queensland, Queensland, Australia
| | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Queensland, Australia.,Australasian Kidney Trials Network, University of Queensland, Queensland, Australia.,Translational Research Institute, Brisbane, Australia
| | - Jonathan C Craig
- College of Medicine and Public Health, Flinders University, South Australia, Australia
| | - Jeremy R Chapman
- Westmead Clinical School, The Westmead Institute for Medical Research, New South Wales, Australia
| | - Bruce A Cooper
- Department of Renal Medicine, Royal North Shore Hospital, New South Wales, Australia
| | - Carol A Pollock
- Northern Clinical School, Kolling Institute of Medical Research, New South Wales, Australia
| | - David C H Harris
- Centre for Transplantation and Renal Research, Westmead Institute for Medical Research, New South Wales
| | - Stephen P McDonald
- Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australian Health and Medical Research Institute, South Australia, Australia.,Adelaide Medical School, University of Adelaide, South Australia, Australia.,Royal Adelaide Hospital, South Australia, Australia
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Au EH, Wong G, Howard K, Chapman JR, Castells A, Roger SD, Bourke MJ, Macaskill P, Turner R, Lim WH, Lok CE, Diekmann F, Cross N, Sen S, Allen RD, Chadban SJ, Pollock CA, Tong A, Teixeira-Pinto A, Yang JY, Kieu A, James L, Craig JC. Factors Associated With Advanced Colorectal Neoplasia in Patients With CKD. Am J Kidney Dis 2021; 79:549-560. [PMID: 34461168 DOI: 10.1053/j.ajkd.2021.07.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 07/16/2021] [Indexed: 12/19/2022]
Abstract
RATIONALE & OBJECTIVE The risk of developing colorectal cancer in patients with chronic kidney disease (CKD) is twice that of the general population, but the factors associated with colorectal cancer are poorly understood. The aim of this study was to identify factors associated with advanced colorectal neoplasia in patients with CKD. STUDY DESIGN Prospective cohort study. SETTING & PARTICIPANTS Patients with CKD stages 3-5, including those treated with maintenance dialysis or transplantation across 11 sites in Australia, New Zealand, Canada, and Spain, were screened for colorectal neoplasia using a fecal immunochemical test (FIT) as part of the Detecting Bowel Cancer in CKD (DETECT) Study. EXPOSURE Baseline characteristics for patients at the time of study enrollment were ascertained, including duration of CKD, comorbidities, and medications. OUTCOME Advanced colorectal neoplasia was identified through a 2-step verification process with colonoscopy following positive FIT and 2-year clinical follow-up for all patients. ANALYTICAL APPROACH Potential factors associated with advanced colorectal neoplasia were explored using multivariable logistic regression. Sensitivity analyses were performed using grouped LASSO (least absolute shrinkage and selection operator) logistic regression. RESULTS Among 1,706 patients who received FIT-based screening-791 with CKD stages 3-5 not receiving kidney replacement therapy (KRT), 418 receiving dialysis, and 497 patients with a functioning kidney transplant-117 patients (6.9%) were detected to have advanced colorectal neoplasia (54 with CKD stages 3-5 without KRT, 34 receiving dialysis, and 29 transplant recipients), including 9 colorectal cancers. The factors found to be associated with advanced colorectal neoplasia included older age (OR per year older, 1.05 [95% CI, 1.03-1.07], P<0.001), male sex (OR, 2.27 [95% CI, 1.45-3.54], P<0.001), azathioprine use (OR, 2.99 [95% CI, 1.40-6.37], P=0.005), and erythropoiesis-stimulating agent use (OR, 1.92 [95% CI, 1.22-3.03], P=0.005). Grouped LASSO logistic regression revealed similar associations between these factors and advanced colorectal neoplasia. LIMITATIONS Unmeasured confounding factors. CONCLUSIONS Older age, male sex, erythropoiesis-stimulating agents, and azathioprine were found to be significantly associated with advanced colorectal neoplasia in patients with CKD.
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Affiliation(s)
- Eric H Au
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia; Centre for Transplant and Renal Research, Westmead Hospital, Westmead, Australia.
| | - Germaine Wong
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia; Centre for Transplant and Renal Research, Westmead Hospital, Westmead, Australia
| | - Kirsten Howard
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Jeremy R Chapman
- Centre for Transplant and Renal Research, Westmead Hospital, Westmead, Australia
| | - Antoni Castells
- Gastroenterology Department, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Simon D Roger
- Department of Renal Medicine, Gosford Hospital, Gosford, Australia
| | - Michael J Bourke
- Department of Gastroenterology, Westmead Hospital, Westmead, Australia
| | - Petra Macaskill
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Robin Turner
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia; Biostatistics Unit, Dunedin School of Medicine, Otago University, Christchurch, New Zealand
| | - Wai H Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Australia
| | - Charmaine E Lok
- Department of Medicine, University Health Network-Toronto General Hospital, Toronto, Ontario, Canada
| | - Fritz Diekmann
- Department of Nephrology and Kidney Transplantation, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Nicholas Cross
- Department of Nephrology and Kidney Transplantation, Christchurch Hospital, Otago University, Christchurch, New Zealand
| | - Shaundeep Sen
- Department of Renal Medicine, Concord Repatriation General Hospital, Concord, Australia
| | - Richard D Allen
- Department of Renal Medicine, Royal Prince Alfred Hospital, and Charles Perkins Centre, University of Sydney, Sydney, Australia
| | - Steven J Chadban
- Department of Renal Medicine, Royal Prince Alfred Hospital, and Charles Perkins Centre, University of Sydney, Sydney, Australia
| | - Carol A Pollock
- Department of Medicine, Northern Clinical School, Kolling Institute of Medical Research, Sydney, Australia
| | - Allison Tong
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Armando Teixeira-Pinto
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Jean Y Yang
- School of Mathematics and Statistics, University of Sydney, Sydney, Australia
| | - Anh Kieu
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Laura James
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Jonathan C Craig
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
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Gutman T, Tong A, Howell M, Dansie K, Hawley CM, Craig JC, Jesudason S, Chapman JR, Johnson DW, Murphy L, Reidlinger D, Crowe S, Duncanson E, Muthuramalingam S, Scholes-Robertson N, Williamson A, McDonald S. Principles and strategies for involving patients in research in chronic kidney disease: report from national workshops. Nephrol Dial Transplant 2021; 35:1585-1594. [PMID: 31093667 DOI: 10.1093/ndt/gfz076] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 03/15/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND There is widespread recognition that research will be more impactful if it arises from partnerships between patients and researchers, but evidence on best practice for achieving this remains limited. METHODS We convened workshops in three Australian cities involving 105 patients/caregivers and 43 clinicians/researchers. In facilitated breakout groups, participants discussed principles and strategies for effective patient involvement in chronic kidney disease research. Transcripts were analysed thematically. RESULTS Five major themes emerged. 'Respecting consumer expertise and commitment' involved valuing unique and diverse experiential knowledge, clarifying expectations and responsibilities, equipping for meaningful involvement and keeping patients 'in the loop'. 'Attuning to individual context' required a preference-based multipronged approach to engagement, reducing the burden of involvement and being sensitive to the patient journey. 'Harnessing existing relationships and infrastructure' meant partnering with trusted clinicians, increasing research exposure in clinical settings, mentoring patient to patient and extending reach through established networks. 'Developing a coordinated approach' enabled power in the collective and united voice, a systematic approach for equitable inclusion and streamlining access to opportunities and trustworthy information. 'Fostering a patient-centred culture' encompassed building a community, facilitating knowledge exchange and translation, empowering health ownership, providing an opportunity to give back and cultivating trust through transparency. CONCLUSIONS Partnering with patients in research requires respect and recognition of their unique, diverse and complementary experiential expertise. Establishing a supportive, respectful research culture, responding to their individual context, coordinating existing infrastructure and centralizing the flow of information may facilitate patient involvement as active partners in research.
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Affiliation(s)
- Talia Gutman
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia.,Centre for Kidney Research, Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Allison Tong
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia.,Centre for Kidney Research, Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Martin Howell
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia.,Centre for Kidney Research, Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Kathryn Dansie
- Australia and New Zealand Dialysis and Transplant Registry, SA Health and Medical Research Institute, Adelaide, SA, Australia
| | - Carmel M Hawley
- Australasian Kidney Trials Network, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,Department of Nephrology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Jonathan C Craig
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia.,Centre for Kidney Research, Children's Hospital at Westmead, Westmead, NSW, Australia.,College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
| | - Shilpanjali Jesudason
- Central and Northern Adelaide Renal and Transplantation Service and Royal Adelaide Hospital, Adelaide, SA, Australia.,Kidney Health Australia, Melbourne, SA, Australia.,Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Jeremy R Chapman
- Westmead Clinical School, Westmead Institute for Medical Research, NSW, Australia
| | - David W Johnson
- Australasian Kidney Trials Network, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.,Department of Nephrology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Lisa Murphy
- Kidney Health Australia, Melbourne, SA, Australia
| | - Donna Reidlinger
- Australasian Kidney Trials Network, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | | | - Emily Duncanson
- Australia and New Zealand Dialysis and Transplant Registry, SA Health and Medical Research Institute, Adelaide, SA, Australia
| | | | - Nicole Scholes-Robertson
- Centre for Kidney Research, Children's Hospital at Westmead, Westmead, NSW, Australia.,BEAT-CKD Consumer Advisory Board, BEAT-CKD, SA, Australia
| | - Amber Williamson
- BEAT-CKD Consumer Advisory Board, BEAT-CKD, SA, Australia.,Queensland Consumer Consultative Committee, Kidney Health Australia, Brisbane, QLD, Australia
| | - Stephen McDonald
- Australia and New Zealand Dialysis and Transplant Registry, SA Health and Medical Research Institute, Adelaide, SA, Australia.,College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia.,Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
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Chapman JR, Baan CC, Bromberg J, Emond JE, Geissler EK, Kaplan B, Tullius SG. COVID-19: A Year on. Transplantation 2021; 105:1-3. [PMID: 33208693 DOI: 10.1097/tp.0000000000003544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Natale P, Gutman T, Howell M, Dansie K, Hawley CM, Cho Y, Viecelli AK, Craig JC, Jesudason S, Chapman JR, Johnson DW, Murphy L, Reidlinger D, Crowe S, Duncanson E, Muthuramalingam S, Scholes-Robertson N, Williamson A, McDonald S, Wong G, Teixeira-Pinto A, Strippoli GFM, Tong A. Recruitment and retention in clinical trials in chronic kidney disease: report from national workshops with patients, caregivers and health professionals. Nephrol Dial Transplant 2020; 35:755-764. [PMID: 32240311 DOI: 10.1093/ndt/gfaa044] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Slow recruitment and poor retention jeopardize the reliability and statistical power of clinical trials, delaying access to effective interventions and increasing costs, as commonly observed in nephrology trials. Involving patients in trial design, recruitment and retention is infrequent but potentially transformational. METHODS We conducted three workshops involving 105 patients/caregivers and 43 health professionals discussing patient recruitment and retention in clinical trials in chronic kidney disease. RESULTS We identified four themes. 'Navigating the unknown'-patients described being unaware of the research question, confused by technical terms, sceptical about findings and feared the risk of harm. 'Wary of added burden'-patients voiced reluctance to attend additional appointments, were unsure of the commitment required or at times felt too unwell and without capacity to participate. 'Disillusioned and disconnected'-some patients felt they were taken for granted, particularly if they did not receive trial results. Participants believed there was no culture of trial participation in kidney disease and an overall lack of awareness about opportunities to participate. To improve recruitment and retention, participants addressed 'Building motivation and interest'. CONCLUSIONS Investigators should establish research consciousness from the time of diagnosis, consider optimal timing for approaching patients, provide comprehensive information in an accessible manner, emphasize current and future relevance to them and their illness, involve trusted clinicians in recruitment and minimize the burden of trial participation. Participation in clinical trials was seen as an opportunity for people to give back to the health system and for future people in their predicament.
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Affiliation(s)
- Patrizia Natale
- Sydney School of Public Health, University of Sydney, New South Wales, Sydney, Australia.,Centre for Kidney Research, Children's Hospital at Westmead, New South Wales, Westmead, Australia.,Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Talia Gutman
- Sydney School of Public Health, University of Sydney, New South Wales, Sydney, Australia.,Centre for Kidney Research, Children's Hospital at Westmead, New South Wales, Westmead, Australia
| | - Martin Howell
- Sydney School of Public Health, University of Sydney, New South Wales, Sydney, Australia.,Centre for Kidney Research, Children's Hospital at Westmead, New South Wales, Westmead, Australia
| | - Kathryn Dansie
- Australia and New Zealand Dialysis and Transplant Registry, SA Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Carmel M Hawley
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Queensland, Australia.,Translational Research Institute, Brisbane, Queensland, Australia.,Department of Nephrology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Yeoungjee Cho
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Queensland, Australia.,Translational Research Institute, Brisbane, Queensland, Australia.,Department of Nephrology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Andrea K Viecelli
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Queensland, Australia.,Department of Nephrology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Jonathan C Craig
- Sydney School of Public Health, University of Sydney, New South Wales, Sydney, Australia.,Centre for Kidney Research, Children's Hospital at Westmead, New South Wales, Westmead, Australia.,College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Shilpanjali Jesudason
- Central and Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Kidney Health Australia, Victoria, Melbourne, Australia.,Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Jeremy R Chapman
- Westmead Clinical School, Westmead Institute for Medical Research, New South Wales, Westmead, Australia
| | - David W Johnson
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Queensland, Australia.,Translational Research Institute, Brisbane, Queensland, Australia.,Department of Nephrology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Lisa Murphy
- Kidney Health Australia, Victoria, Melbourne, Australia
| | - Donna Reidlinger
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Queensland, Australia.,Translational Research Institute, Brisbane, Queensland, Australia
| | | | - Emily Duncanson
- Australia and New Zealand Dialysis and Transplant Registry, SA Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Shyamsundar Muthuramalingam
- Sydney School of Public Health, University of Sydney, New South Wales, Sydney, Australia.,Australia and New Zealand Dialysis and Transplant Registry, SA Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Nicole Scholes-Robertson
- Sydney School of Public Health, University of Sydney, New South Wales, Sydney, Australia.,Centre for Kidney Research, Children's Hospital at Westmead, New South Wales, Westmead, Australia
| | - Amber Williamson
- BEAT-CKD Consumer Advisory Board, Sydney, New South Wales, Australia.,Kidney Health Australia, Queensland Consumer Consultative Committee, Brisbane, Queensland, Australia
| | - Stephen McDonald
- Australia and New Zealand Dialysis and Transplant Registry, SA Health and Medical Research Institute, Adelaide, South Australia, Australia.,Central and Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Germaine Wong
- Sydney School of Public Health, University of Sydney, New South Wales, Sydney, Australia.,Centre for Kidney Research, Children's Hospital at Westmead, New South Wales, Westmead, Australia.,Westmead Clinical School, Westmead Institute for Medical Research, New South Wales, Westmead, Australia
| | - Armando Teixeira-Pinto
- Sydney School of Public Health, University of Sydney, New South Wales, Sydney, Australia.,Centre for Kidney Research, Children's Hospital at Westmead, New South Wales, Westmead, Australia
| | - Giovanni F M Strippoli
- Sydney School of Public Health, University of Sydney, New South Wales, Sydney, Australia.,Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy.,Cochrane Kidney and Transplant, Centre for Kidney Research, Children's Hospital at Westmead, New South Wales, Westmead, Australia
| | - Allison Tong
- Sydney School of Public Health, University of Sydney, New South Wales, Sydney, Australia.,Centre for Kidney Research, Children's Hospital at Westmead, New South Wales, Westmead, Australia
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Krishnan A, Teixeira-Pinto A, Lim WH, Howard K, Chapman JR, Castells A, Roger SD, Bourke MJ, Macaskill P, Williams G, Lok CE, Diekmann F, Cross N, Sen S, Allen RDM, Chadban SJ, Pollock CA, Turner R, Tong A, Yang JYH, Williams N, Au E, Kieu A, James L, Francis A, Wong G, Craig JC. Health-Related Quality of Life in People Across the Spectrum of CKD. Kidney Int Rep 2020; 5:2264-2274. [PMID: 33305120 PMCID: PMC7710842 DOI: 10.1016/j.ekir.2020.09.028] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 09/08/2020] [Indexed: 11/30/2022] Open
Abstract
Introduction People with chronic kidney disease (CKD) experience reduced quality of life (QoL) because of the high symptom and treatment burden. Limited data exist on the factors associated with overall and domain-specific QoL across all CKD stages. Methods Using data from a prospective, multinational study (Australia, New Zealand, Canada, and Spain) in 1696 participants with CKD, we measured overall and domain-specific QoL (pain, self-care, activity, mobility, anxiety/depression) using the EuroQoL, 5 dimension, 3 level. Multivariable linear regression and logistic modeling were used to determine factors associated with overall and domain-specific QoL. Results QoL for patients with CKD stages 3 to 5 (n = 787; mean, 0.81; SD, 0.20) was higher than in patients on dialysis (n = 415; mean, 0.76; SD, 0.24) but lower than in kidney transplant recipients (n = 494; mean, 0.84; SD, 0.21). Factors associated with reduced overall QoL (β [95% confidence intervals]) included being on dialysis (compared with CKD stages 3–5: –0.06 [–0.08 to –0.03]), female sex (–0.03 [–0.05 to –0.006]), lower educational attainment (– 0.04 [–0.06 to –0.02), lacking a partner (–0.04 [–0.06 to –0.02]), having diabetes (–0.05 [–0.07 to –0.02]), history of stroke (–0.09 [–0.13 to –0.05]), cardiovascular disease (–0.06 [–0.08 to –0.03]), and cancer (–0.03 [–0.06 to –0.009]). Pain (43%) and anxiety/depression (30%) were the most commonly affected domains, with dialysis patients reporting decrements in all 5 domains. Predictors for domain-specific QoL included being on dialysis, presence of comorbidities, lower education, female sex, and lack of a partner. Conclusions Being on dialysis, women with CKD, those with multiple comorbidities, lack of a partner, and lower educational attainment were associated with lower QoL across all stages of CKD.
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Affiliation(s)
- Anoushka Krishnan
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Australia
| | - Armando Teixeira-Pinto
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Wai H Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Australia
| | - Kirsten Howard
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Jeremy R Chapman
- Centre for Transplant and Renal Research, Westmead Hospital, Westmead, Australia
| | - Antoni Castells
- Gastroenterology Department, Hospital Clinic, University of Barcelona, IDIBAPS, CIBEREHD, Barcelona, Spain
| | - Simon D Roger
- Department of Renal Medicine, Gosford Hospital, Gosford, Australia
| | - Michael J Bourke
- Department of Gastroenterology, Westmead Hospital, Westmead, Australia
| | - Petra Macaskill
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Gabrielle Williams
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Charmaine E Lok
- Department of Medicine, University Health Network-Toronto General Hospital, Toronto, Ontario, Canada
| | - Fritz Diekmann
- Department of Nephrology and Kidney Transplantation, Hospital Clínic, Barcelona, Spain
| | - Nicholas Cross
- Department of Nephrology and Kidney Transplantation, Christchurch Hospital and Otago University, Christchurch, New Zealand
| | - Shaundeep Sen
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Department of Renal Medicine, Concord Repatriation General Hospital, Concord, Australia
| | - Richard D M Allen
- Department of Renal Medicine, Royal Prince Alfred Hospital, and Charles Perkins Centre, The University of Sydney, Sydney, Australia
| | - Steven J Chadban
- Department of Renal Medicine, Royal Prince Alfred Hospital, and Charles Perkins Centre, The University of Sydney, Sydney, Australia
| | - Carol A Pollock
- Department of Medicine, Northern Clinical School, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Robin Turner
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Biostatistics Unit, Dunedin School of Medicine, University of Otago, Christchurch, New Zealand
| | - Allison Tong
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Jean Y H Yang
- School of Mathematics and Statistics, The University of Sydney, Sydney, Australia
| | - Narelle Williams
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Eric Au
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Anh Kieu
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Laura James
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Anna Francis
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Germaine Wong
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Centre for Transplant and Renal Research, Westmead Hospital, Westmead, Australia
| | - Jonathan C Craig
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
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13
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Chan S, Ng S, Chan HP, Pascoe EM, Playford EG, Wong G, Chapman JR, Lim WH, Francis RS, Isbel NM, Campbell SB, Hawley CM, Johnson DW. Perioperative antibiotics for preventing post-surgical site infections in solid organ transplant recipients. Cochrane Database Syst Rev 2020; 8:CD013209. [PMID: 32799356 PMCID: PMC7437398 DOI: 10.1002/14651858.cd013209.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Solid organ transplant recipients are at high risk for infections due to the complexity of surgical procedures combined with the impact of immunosuppression. No consensus exists on the role of antibiotics for surgical site infections in solid organ transplant recipients. OBJECTIVES To assess the benefits and harms of prophylactic antimicrobial agents for preventing surgical site infections in solid organ transplant recipients. SEARCH METHODS The Cochrane Kidney and Transplant Register of Studies was searched up to 21 April 2020 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal, and ClinicalTrials.gov. SELECTION CRITERIA All randomised controlled trials (RCTs) and quasi-RCTs in any language assessing prophylactic antibiotics in preventing surgical site infections in solid organ transplant recipients at any time point after transplantation. DATA COLLECTION AND ANALYSIS Two authors independently determined study eligibility, assessed quality, and extracted data. Primary outcomes were surgical site infections and antimicrobial resistance. Other outcomes included urinary tract infections, pneumonias and septicaemia, death (any cause), graft loss, graft rejection, graft function, adverse reactions to antimicrobial agents, and outcomes identified by the Standardised Outcomes of Nephrology Group (SONG), specifically graft health, cardiovascular disease, cancer and life participation. Summary effect estimates were obtained using a random-effects model and results were expressed as risk ratios (RR) and 95% confidence intervals (CI). The quality of the evidence was assessed using the risk of bias and the GRADE approach. MAIN RESULTS We identified eight eligible studies (718 randomised participants). Overall, five studies (248 randomised participants) compared antibiotics versus no antibiotics, and three studies (470 randomised participants) compared extended duration versus short duration antibiotics. Risk of bias was assessed as high for performance bias (eight studies), detection bias (eight studies) and attrition bias (two studies). It is uncertain whether antibiotics reduce the incidence of surgical site infections as the certainty of the evidence has been assessed as very low (RR 0.42, 95% CI 0.21 to 0.85; 5 studies, 226 participants; I2 = 25%). The certainty of the evidence was very low for all other reported outcomes (death, graft loss, and other infections). It is uncertain whether extended duration antibiotics reduces the incidence of surgical site infections in either solid organ transplant recipients (RR 1.19, 95% CI 0.58 to 2.48; 2 studies, 302 participants; I2 = 0%) or kidney-only transplant recipients (RR 0.50, 95% CI 0.05 to 5.48; 1 study, 205 participants) as the certainty of the evidence has been assessed as very low. The certainty of the evidence was very low for all other reported outcomes (death, graft loss, and other infections). None of the eight included studies evaluated antimicrobial agent adverse reactions, graft health, cardiovascular disease, cancer, life participation, biochemical and haematological parameters, intervention cost, hospitalisation length, or overall hospitalisation costs. AUTHORS' CONCLUSIONS Due to methodological limitations, risk of bias and significant heterogeneity, the current evidence for the use of prophylactic perioperative antibiotics in transplantation is of very low quality. Further high quality, adequately powered RCTs would help better inform clinical practice.
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Affiliation(s)
- Samuel Chan
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | - Samantha Ng
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | - Hooi P Chan
- General Practice Queensland, Brisbane, Australia
| | - Elaine M Pascoe
- Department of Biostatistics, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | | | - Germaine Wong
- School of Public Health, The University of Sydney, Sydney, Australia
| | - Jeremy R Chapman
- Department of Nephrology, Westmead Clinical School, Sydney, Australia
| | - Wai H Lim
- Department of Nephrology, Sir Charles Gardiner Hospital, Perth, Australia
| | - Ross S Francis
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | - Nicole M Isbel
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | - Scott B Campbell
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | - Carmel M Hawley
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
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14
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Shingde R, Calisa V, Craig JC, Chapman JR, Webster AC, Pleass H, O’Connell PJ, Allen R, Robertson P, Yuen L, Kable K, Nankivell B, Rogers NM, Wong G. Relative survival and quality of life benefits of pancreas–kidney transplantation, deceased kidney transplantation and dialysis in type 1 diabetes mellitus—a probabilistic simulation model. Transpl Int 2020; 33:1393-1404. [DOI: 10.1111/tri.13679] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 04/27/2020] [Accepted: 06/17/2020] [Indexed: 12/16/2022]
Affiliation(s)
- Rashmi Shingde
- Renal Unit Westmead Hospital Westmead NSW Australia
- Centre for Kidney Research Kids Research InstituteThe Children’s Hospital at Westmead Westmead NSW Australia
| | - Vaishnavi Calisa
- Renal Unit Westmead Hospital Westmead NSW Australia
- Centre for Kidney Research Kids Research InstituteThe Children’s Hospital at Westmead Westmead NSW Australia
| | - Jonathan C. Craig
- College of Medicine and Public Health Flinders University Adelaide SA Australia
| | - Jeremy R. Chapman
- Centre for Transplant and Renal Research Westmead Institute for Medical Research Westmead NSW Australia
| | - Angela C. Webster
- Centre for Kidney Research Kids Research InstituteThe Children’s Hospital at Westmead Westmead NSW Australia
- Sydney School of Public Health University of Sydney Sydney NSW Australia
| | - Henry Pleass
- Centre for Transplant and Renal Research Westmead Institute for Medical Research Westmead NSW Australia
- Department of Surgery Westmead Hospital Westmead NSW Australia
| | - Philip J. O’Connell
- Renal Unit Westmead Hospital Westmead NSW Australia
- Centre for Transplant and Renal Research Westmead Institute for Medical Research Westmead NSW Australia
| | - Richard Allen
- Centre for Transplant and Renal Research Westmead Institute for Medical Research Westmead NSW Australia
- Department of Surgery Westmead Hospital Westmead NSW Australia
| | - Paul Robertson
- Centre for Transplant and Renal Research Westmead Institute for Medical Research Westmead NSW Australia
| | - Lawrence Yuen
- Centre for Transplant and Renal Research Westmead Institute for Medical Research Westmead NSW Australia
- Department of Surgery Westmead Hospital Westmead NSW Australia
| | - Kathy Kable
- Centre for Transplant and Renal Research Westmead Institute for Medical Research Westmead NSW Australia
| | - Brian Nankivell
- Centre for Transplant and Renal Research Westmead Institute for Medical Research Westmead NSW Australia
| | - Natasha M. Rogers
- Renal Unit Westmead Hospital Westmead NSW Australia
- Centre for Transplant and Renal Research Westmead Institute for Medical Research Westmead NSW Australia
| | - Germaine Wong
- Renal Unit Westmead Hospital Westmead NSW Australia
- Centre for Kidney Research Kids Research InstituteThe Children’s Hospital at Westmead Westmead NSW Australia
- College of Medicine and Public Health Flinders University Adelaide SA Australia
- Centre for Transplant and Renal Research Westmead Institute for Medical Research Westmead NSW Australia
- Sydney School of Public Health University of Sydney Sydney NSW Australia
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15
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Yilmaz E, von Glinski A, Schildhauer TA, Iwanaga J, Ishak B, Abdul-Jabbar A, Moisi M, Oskouian RJ, Tubbs RS, Chapman JR. What are the best trajectories for multiple iliac screw placement in spine surgeries? An anatomical, radiographical and morphometric cadaver analysis. Injury 2020; 51:1294-1300. [PMID: 32201116 DOI: 10.1016/j.injury.2020.02.095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 02/15/2020] [Indexed: 02/02/2023]
Affiliation(s)
- E Yilmaz
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, United States; Seattle Science Foundation, Seattle, Washington, United States; Department of Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bürkle-de-la-Camp-Platz 1 44789, Bochum, Germany.
| | - A von Glinski
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, United States; Seattle Science Foundation, Seattle, Washington, United States; Department of Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bürkle-de-la-Camp-Platz 1 44789, Bochum, Germany; Hansjörg Wyss Hip and Pelvic Center, Swedish Hospital, Seattle, Washington, United States
| | - T A Schildhauer
- Department of Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bürkle-de-la-Camp-Platz 1 44789, Bochum, Germany
| | - J Iwanaga
- Seattle Science Foundation, Seattle, Washington, United States
| | - B Ishak
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, United States; Seattle Science Foundation, Seattle, Washington, United States
| | - A Abdul-Jabbar
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, United States; Seattle Science Foundation, Seattle, Washington, United States
| | - M Moisi
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, United States; Seattle Science Foundation, Seattle, Washington, United States
| | - R J Oskouian
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, United States; Seattle Science Foundation, Seattle, Washington, United States
| | - R S Tubbs
- Seattle Science Foundation, Seattle, Washington, United States; Department of Anatomical Sciences, St. George's University, St. George's, Grenada
| | - J R Chapman
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, United States; Seattle Science Foundation, Seattle, Washington, United States
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16
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Hahn D, Hodson EM, Hamiwka LA, Lee VWS, Chapman JR, Craig JC, Webster AC. Target of rapamycin inhibitors (TOR-I; sirolimus and everolimus) for primary immunosuppression in kidney transplant recipients. Cochrane Database Syst Rev 2019; 12:CD004290. [PMID: 31840244 PMCID: PMC6953317 DOI: 10.1002/14651858.cd004290.pub3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Kidney transplantation is the therapy of choice for many patients with end-stage kidney disease (ESKD) with an improvement in survival rates and satisfactory short term graft survival. However, there has been little improvement in long-term survival. The place of target of rapamycin inhibitors (TOR-I) (sirolimus, everolimus), which have different modes of action from other commonly used immunosuppressive agents, in kidney transplantation remains uncertain. This is an update of a review first published in 2006. OBJECTIVES To evaluate the short and long-term benefits and harms of TOR-I (sirolimus and everolimus) when used in primary immunosuppressive regimens for kidney transplant recipients. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 20 September 2019 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register were identified through searches of CENTRAL, MEDLINE and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA All randomised controlled trials (RCTs) and quasi-RCTs in which drug regimens, containing TOR-I commenced within seven days of transplant, were compared to alternative drug regimens, were included without age restriction, dosage or language of report. DATA COLLECTION AND ANALYSIS Three authors independently assessed study eligibility, risk of bias, and extracted data. Results were reported as risk ratios (RR) with 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) with 95% CI for continuous outcomes. Statistical analyses were performed using the random-effects model. The certainty of the evidence was assessed using GRADE MAIN RESULTS: Seventy studies (17,462 randomised participants) were included; eight studies included two comparisons to provide 78 comparisons. Outcomes were reported at six months to three years post transplant. Risk of bias was judged to be low for sequence generation in 25 studies, for allocation concealment in 23 studies, performance bias in four studies, detection bias in 65 studies, attrition bias in 45 studies, selective reporting bias in 48 studies, and for other potential bias in three studies. Risk of bias was judged to be at high risk of bias for sequence generation in two studies, allocation concealment in two studies, performance bias in 61 studies, detection bias in one study, attrition bias in four studies, for selective reporting bias in 11 studies and for other potential risk of bias in 46 studies. Compared with CNI and antimetabolite, TOR-I with antimetabolite probably makes little or no difference to death (RR 1.31, 95% CI 0.87 to 1.98; 19 studies) or malignancies (RR 0.86, 95% CI 0.50 to 1.48; 10 studies); probably increases graft loss censored for death (RR 1.32, 95% CI 0.96 to 1.81; 15 studies), biopsy-proven acute rejection (RR 1.60, 95% CI 1.25 to 2.04; 15 studies), need to change treatment (RR 2.42, 95% CI 1.88 to 3.11; 14 studies) and wound complications (RR 2.56, 95% CI 1.94 to 3.36; 12 studies) (moderate certainty evidence); but reduces CMV infection (RR 0.43, 95% CI 0.29 to 0.63; 13 studies) (high certainty evidence). Compared with antimetabolites and CNI, TOR-I with CNI probably makes little or no difference to death (RR 1.06, 95% CI 0.84 to 1.33; 31 studies), graft loss censored for death (RR 1.09, 95% CI 0.82 to 1.45; 26 studies), biopsy-proven acute rejection (RR 0.95, 95% CI 0.81 to 1.12; 24 studies); and malignancies (RR 0.83, 95% CI 0.64 to 1.07; 17 studies); probably increases the need to change treatment (RR 1.56, 95% CI 1.28 to 1.90; 25 studies), and wound complications (RR 1.56, 95% CI 1.28 to 1.91; 17 studies); but probably reduces CMV infection (RR 0.44, 95% CI 0.34 to 0.58; 25 studies) (moderate certainty evidence). Lower dose TOR-I and standard dose CNI compared with higher dose TOR-I and reduced dose CNI probably makes little or no difference to death (RR 1.07, 95% CI 0.64 to 1.78; 9 studies), graft loss censored for death (RR 1.09, 95% CI 0.54 to 2.20; 8 studies), biopsy-proven acute rejection (RR 0.87, 95% CI 0.67 to 1.13; 8 studies), and CMV infection (RR 1.42, 95% CI 0.78 to 2.60; 5 studies) (moderate certainty evidence); and may make little or no difference to wound complications (RR 0.95, 95% CI 0.53 to 1.71; 3 studies), malignancies (RR 1.04, 95% CI 0.36 to 3.04; 7 studies), and the need to change treatments (RR 1.18, 95% CI 0.58 to 2.42; 5 studies) (low certainty evidence). Lower dose of TOR-I compared with higher doses probably makes little or no difference to death (RR 0.84, 95% CI 0.67 to 1.06; 13 studies), graft loss censored for death (RR 0.92, 95% CI 0.71 to 1.19; 12 studies), biopsy-proven acute rejection (RR 1.26, 95% CI 1.10 to 1.43; 11 studies), CMV infection (RR 0.87, 95% CI 0.63 to 1.21; 9 studies), wound complications (RR 0.92, 95% CI 0.66 to 1.29; 7 studies), and malignancy (RR 0.84, 95% CI 0.54 to 1.32; 10 studies) (moderate certainty evidence); and may make little or no difference to the need to change treatments (RR 0.91, 95% CI 0.78 to 1.05; 10 studies) (low certainty evidence). It is uncertain whether sirolimus and everolimus differ in their effects on kidney function and lipid levels because the certainty of the evidence is very low based on a single small study with only three months of follow-up. AUTHORS' CONCLUSIONS In studies with follow-up to three years, TOR-I with an antimetabolite increases the risk of graft loss and acute rejection compared with CNI and an antimetabolite. TOR-I with CNI potentially offers an alternative to an antimetabolite with CNI as rates of graft loss and acute rejection are similar between interventions and TOR-I regimens are associated with a reduced risk of CMV infections. Wound complications and the need to change immunosuppressive medications are higher with TOR-I regimens. While further new studies are not required, longer-term follow-up data from participants in existing methodologically robust RCTs are needed to determine how useful immunosuppressive regimens, which include TOR-I, are in maintaining kidney transplant function and survival beyond three years.
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Affiliation(s)
- Deirdre Hahn
- The Children's Hospital at WestmeadDepartment of NephrologyLocked Bag 4001WestmeadNSWAustralia2145
| | - Elisabeth M Hodson
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchLocked Bag 4001WestmeadNSWAustralia2145
| | - Lorraine A Hamiwka
- University of Calgary/Alberta Children's HospitalDepartment of Medicine/Pediatrics2888 Shaganappi Trail NW Children's HospitalCalgaryAlbertaCanadaT3B 6A8
| | - Vincent WS Lee
- Westmead & Blacktown HospitalsDepartment of Renal MedicineDarcy RdWestmeadNSWAustralia2145
- The University of Sydney at WestmeadCentre for Transplant and Renal Research, Westmead Millennium InstituteWestmeadAustralia
| | - Jeremy R Chapman
- Westmead Millennium Institute, The University of Sydney at WestmeadCentre for Transplant and Renal ResearchDarcy RdWestmeadNSWAustralia2145
| | - Jonathan C Craig
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchLocked Bag 4001WestmeadNSWAustralia2145
- Flinders UniversityCollege of Medicine and Public HealthAdelaideSAAustralia5001
| | - Angela C Webster
- The University of Sydney at WestmeadCentre for Transplant and Renal Research, Westmead Millennium InstituteWestmeadAustralia
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
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17
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Wong G, Hope RL, Howard K, Chapman JR, Castells A, Roger SD, Bourke MJ, Macaskill P, Turner R, Williams G, Lim WH, Lok CE, Diekman F, Cross N, Sen S, Allen RDM, Chadban SJ, Pollock CA, Tong A, Teixeira-Pinto A, Yang JYH, Williams N, Au E, Kieu A, James L, Craig JC. Authors' Reply. J Am Soc Nephrol 2019; 30:2276-2277. [PMID: 31597717 DOI: 10.1681/asn.2019090889] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
- Germaine Wong
- Faculty of Medicine and Health, Sydney School of Public Health, .,Centre for Transplant and Renal Research and
| | - Richard L Hope
- Department of Gastroenterology, Westmead Hospital, Westmead, Australia
| | - Kirsten Howard
- Faculty of Medicine and Health, Sydney School of Public Health
| | | | - Antoni Castells
- Gastroenterology Department, Hospital Clinic, Institute of Biomedical Research August Pi i Sunyer, Center for Biomedical Research in Network of Hepatic and Digestive Diseases, University of Barcelona, Barcelona, Spain
| | - Simon D Roger
- Department of Renal Medicine, Gosford Hospital, Gosford, Australia
| | - Michael J Bourke
- Department of Gastroenterology, Westmead Hospital, Westmead, Australia
| | - Petra Macaskill
- Faculty of Medicine and Health, Sydney School of Public Health
| | - Robin Turner
- Faculty of Medicine and Health, Sydney School of Public Health.,Biostatistics Unit, Dunedin School of Medicine, University of Otago, Christchurch, New Zealand
| | | | - Wai H Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Australia
| | - Charmaine E Lok
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Fritz Diekman
- Department of Nephrology and Kidney Transplantation, Hospital Clínic, Barcelona, Spain
| | - Nicholas Cross
- Department of Nephrology and Kidney Transplantation, Christchurch Hospital and Otago University, Christchurch, New Zealand
| | - Shaundeep Sen
- Department of Renal Medicine, Concord Repatriation General Hospital, Concord, Australia
| | - Richard D M Allen
- Department of Renal Medicine, Royal Prince Alfred Hospital, Camperdown, Sydney, Australia.,Charles Perkins Centre, and
| | - Steven J Chadban
- Department of Renal Medicine, Royal Prince Alfred Hospital, Camperdown, Sydney, Australia.,Charles Perkins Centre, and
| | - Carol A Pollock
- Department of Medicine, Northern Clinical School, Kolling Institute of Medical Research, St. Leonards, Australia
| | - Allison Tong
- Faculty of Medicine and Health, Sydney School of Public Health
| | | | - Jean Y H Yang
- School of Mathematics and Statistics, The University of Sydney, Sydney, Australia
| | | | - Eric Au
- Faculty of Medicine and Health, Sydney School of Public Health,
| | - Anh Kieu
- Faculty of Medicine and Health, Sydney School of Public Health
| | - Laura James
- Faculty of Medicine and Health, Sydney School of Public Health
| | - Jonathan C Craig
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
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18
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Abstract
Cancer is the second most common cause of mortality and morbidity in kidney transplant recipients after cardiovascular disease. Kidney transplant recipients have at least a twofold higher risk of developing or dying from cancer than the general population. The increased risk of de novo and recurrent cancer in transplant recipients is multifactorial and attributed to oncogenic viruses, immunosuppression and altered T cell immunity. Transplant candidates and potential donors should be screened for cancer as part of the assessment process. For potential recipients with a prior history of cancer, waiting periods of 2-5 years after remission - largely depending on the cancer type and stage of initial cancer diagnosis - are recommended. Post-transplantation cancer screening needs to be tailored to the individual patient, considering the cancer risk of the individual, comorbidities, overall prognosis and the screening preferences of the patient. In kidney transplant recipients diagnosed with cancer, treatment includes conventional approaches, such as radiotherapy and chemotherapy, together with consideration of altering immunosuppression. As the benefits of transplantation compared with dialysis in potential transplant candidates with a history of cancer have not been assessed, current clinical practice relies on evidence from observational studies and registry analyses.
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Affiliation(s)
- Eric Au
- Centre for Transplant and Renal Research, Westmead Hospital, Westmead, New South Wales, Australia
| | - Germaine Wong
- Centre for Transplant and Renal Research, Westmead Hospital, Westmead, New South Wales, Australia.,Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Jeremy R Chapman
- Centre for Transplant and Renal Research, Westmead Hospital, Westmead, New South Wales, Australia.
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19
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Ralph AF, Butow P, Craig JC, Chapman JR, Gill JS, Kanellis J, Tong A. Clinicians' attitudes and approaches to evaluating the potential living kidney donor-recipient relationship: An interview study. Nephrology (Carlton) 2019; 24:252-262. [PMID: 29437270 DOI: 10.1111/nep.13238] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2018] [Indexed: 11/28/2022]
Abstract
AIM Careful assessment of the potential donor-recipient relationship is recommended by guidelines to prevent undue coercion, and to ensure realistic expectations and genuine motivations. However, relationships are complex, nuanced and value-laden, and can be challenging to evaluate in living kidney donation. We aimed to describe the attitudes and approaches of transplant clinicians towards assessing the relationship between potential living kidney donors and their recipients. METHODS Semi-structured interviews were conducted with 54 transplant clinicians (nephrologists, surgeons, coordinators, social workers, psychiatrists and psychologists) from 32 transplant centres across nine countries including Australia, United States, Canada and New Zealand. Transcripts were analyzed thematically. RESULTS Four themes were identified: protecting against vulnerability and premature decisions (ensuring genuine motivation, uncovering precarious dynamics and pre-empting conflict, shared accountability, relying on specialty psychosocial expertise, trusting intimate bonds, tempering emotional impulsivity); safeguarding against coercion (discerning power imbalance, justified inquiry, awareness of impression management); minimizing potential threat to relationships (preserving the bond, giving equitable attention to donors and recipients, ensuring realistic expectations); and ambiguities in making judgments (adjudicating appropriateness and authenticity of relationships, questioning professional intervening, uncertainties in subjective and emotional assessments). CONCLUSIONS Clinicians felt ethically compelled to minimize the risk of undue coercion and to protect donors and recipients when evaluating the donor-recipient relationship. However, disentangling voluntariness and altruism from potential undisclosed pressures to enact societal and family duty, making decisions within this complex, multi-stakeholder context, and avoiding the imposition of undue paternalism and donor autonomy, were challenging. Multidisciplinary expertise and practical strategies for managing uncertainties are required.
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Affiliation(s)
- Angelique F Ralph
- Sydney School of Public Health, The Children's Hospital at Westmead, Sydney, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia.,School of Psychology, The University of Sydney, Melbourne, Australia
| | - Phyllis Butow
- School of Psychology, The University of Sydney, Melbourne, Australia.,Psycho-oncology Co-operative Research Group, The University of Sydney, Melbourne, Australia.,Centre for Medical Psychology & Evidence-based Decision-making, The University of Sydney, Melbourne, Australia
| | - Jonathan C Craig
- Sydney School of Public Health, The Children's Hospital at Westmead, Sydney, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia
| | - Jeremy R Chapman
- Centre for Transplant and Renal Research, The University of Sydney, Melbourne, Australia
| | - John S Gill
- Division of Nephrology, University of British Columbia, Canada
| | - John Kanellis
- Department of Nephrology, Monash Health and Centre for Inflammatory Diseases, Monash University, Melbourne, Australia
| | - Allison Tong
- Sydney School of Public Health, The Children's Hospital at Westmead, Sydney, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia
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20
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Li J, Shingde M, Nankivell BJ, Tchan MC, Bose B, Chapman JR, Kable K, Kim SK, Vucak-Dzumhur M, Wong G, Rangan GK. Adenine Phosphoribosyltransferase Deficiency: A Potentially Reversible Cause of CKD. Kidney Int Rep 2019; 4:1161-1170. [PMID: 31440706 PMCID: PMC6698309 DOI: 10.1016/j.ekir.2019.04.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 04/26/2019] [Accepted: 04/29/2019] [Indexed: 11/26/2022] Open
Affiliation(s)
- Jennifer Li
- Department of Renal Medicine, Westmead Hospital, Western Sydney Local Health District, Sydney, NSW, Australia.,Centre for Transplant and Renal Research, Westmead Institute for Medical Research, The University of Sydney, NSW, Australia
| | - Meena Shingde
- Department of Pathology, Westmead Hospital, Western Sydney Local Health District, Sydney, NSW, Australia
| | - Brian J Nankivell
- Department of Renal Medicine, Westmead Hospital, Western Sydney Local Health District, Sydney, NSW, Australia
| | - Michel C Tchan
- Department of Genetic Medicine, Westmead Hospital, Sydney, NSW, Australia
| | - Bhadran Bose
- Department of Renal Medicine, Nepean Hospital, Nepean Blue Mountains Local Health District, Sydney, NSW, Australia
| | - Jeremy R Chapman
- Department of Renal Medicine, Westmead Hospital, Western Sydney Local Health District, Sydney, NSW, Australia.,Centre for Transplant and Renal Research, Westmead Institute for Medical Research, The University of Sydney, NSW, Australia
| | - Kathy Kable
- Department of Renal Medicine, Westmead Hospital, Western Sydney Local Health District, Sydney, NSW, Australia
| | - Sul Ki Kim
- Department of Renal Medicine, Westmead Hospital, Western Sydney Local Health District, Sydney, NSW, Australia
| | - Mirna Vucak-Dzumhur
- Department of Renal Medicine, Westmead Hospital, Western Sydney Local Health District, Sydney, NSW, Australia
| | - Germaine Wong
- Department of Renal Medicine, Westmead Hospital, Western Sydney Local Health District, Sydney, NSW, Australia
| | - Gopala K Rangan
- Department of Renal Medicine, Westmead Hospital, Western Sydney Local Health District, Sydney, NSW, Australia.,Centre for Transplant and Renal Research, Westmead Institute for Medical Research, The University of Sydney, NSW, Australia
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21
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Nankivell BJ, Agrawal N, Sharma A, Taverniti A, P'Ng CH, Shingde M, Wong G, Chapman JR. The clinical and pathological significance of borderline T cell-mediated rejection. Am J Transplant 2019; 19:1452-1463. [PMID: 30501008 DOI: 10.1111/ajt.15197] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Revised: 10/28/2018] [Accepted: 11/15/2018] [Indexed: 01/25/2023]
Abstract
The pathological diagnosis of borderline rejection (BL-R) denotes possible T cell-mediated rejection (TCMR), but its clinical significance is uncertain. This single-center, cross-sectional cohort study compared the functional and histological outcomes of consecutive BL-R diagnoses (n = 146) against normal controls (n = 826) and acute TCMR (n = 55) from 551 renal transplant recipients. BL-R was associated with the following: contemporaneous renal dysfunction, acute tubular necrosis, and chronic tubular atrophy (P < .001); progressive tubular injury with fibrosis by longitudinal sequential histology (45.3% at 1 year); increased subsequent acute rejection (39.4%), allograft failure (P < .001), and patient mortality (P = .007). BL-R detected by biopsy indicated for impaired function was followed by suboptimal functional recovery (46.3%), persistent inflammation (27.2%), and acute rejection episodes (50.0%) despite antirejection treatment in 83.3%. By 1 year after BL-R, the incidence of new-onset microvascular inflammation (9.3%), C4d staining (22.3%), transplant glomerulopathy (13.3%), and de novo donor-specific antibodies (31.5%) exceeded normal controls (P < .05-.001). BL-R inflammation in protocol biopsy persisted in 28.0% and progressed to acute rejection in 32.6%; however, it resolved in 61.6% of the untreated cases. In summary, BL-R is a heterogeneous diagnostic grouping, ranging from mild inconsequential inflammation to clinically significant TCMR, which is capable of immune-mediated tubular injury resulting in inferior functional, immunological, and histological consequences.
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Affiliation(s)
| | - Nidhi Agrawal
- Department of Renal Medicine, Westmead Hospital, Sydney, Australia
| | - Ankit Sharma
- Department of Renal Medicine, Westmead Hospital, Sydney, Australia.,School of Public Health, University of Sydney, Sydney, Australia.,Centre for Kidney Research, Children's Hospital at Westmead, Sydney, Australia
| | - Anne Taverniti
- Centre for Kidney Research, Children's Hospital at Westmead, Sydney, Australia
| | - Chow H P'Ng
- Tissue Pathology and Diagnostic Oncology, ICPMR, Sydney, Australia
| | - Meena Shingde
- Tissue Pathology and Diagnostic Oncology, ICPMR, Sydney, Australia
| | - Germaine Wong
- Department of Renal Medicine, Westmead Hospital, Sydney, Australia.,School of Public Health, University of Sydney, Sydney, Australia.,Centre for Kidney Research, Children's Hospital at Westmead, Sydney, Australia
| | - Jeremy R Chapman
- Department of Renal Medicine, Westmead Hospital, Sydney, Australia
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22
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Wong G, Hope RL, Howard K, Chapman JR, Castells A, Roger SD, Bourke MJ, Macaskill P, Turner R, Williams G, Lim WH, Lok CE, Diekmann F, Cross NB, Sen S, Allen RDM, Chadban SJ, Pollock CA, Tong A, Teixeira-Pinto A, Yang JYH, Williams N, Au EHK, Kieu A, James L, Craig JC. One-Time Fecal Immunochemical Screening for Advanced Colorectal Neoplasia in Patients with CKD (DETECT Study). J Am Soc Nephrol 2019; 30:1061-1072. [PMID: 31040191 DOI: 10.1681/asn.2018121232] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Accepted: 02/25/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND In patients with CKD, the risk of developing colorectal cancer is high and outcomes are poor. Screening using fecal immunochemical testing (FIT) is effective in reducing mortality from colorectal cancer, but performance characteristics of FIT in CKD are unknown. METHODS To determine the detection rates and performance characteristics of FIT for advanced colorectal neoplasia (ACN) in patients with CKD, we used FIT to prospectively screen patients aged 35-74 years with CKD (stages 3-5 CKD, dialysis, and renal transplant) from 11 sites in Australia, New Zealand, Canada, and Spain. All participants received clinical follow-up at 2 years. We used a two-step reference standard approach to estimate disease status. RESULTS Overall, 369 out of 1706 patients who completed FIT (21.6%) tested positive; 323 (87.5%) underwent colonoscopies. A total of 1553 (91.0%) completed follow-up; 82 (4.8%) had died and 71 (4.2%) were lost. The detection rate of ACN using FIT was 6.0% (5.6%, 7.4%, and 5.6% for stages 3-5 CKD, dialysis, and transplant). Sensitivity, specificity, and positive and negative predictive values of FIT for ACN were 0.90, 0.83, 0.30, and 0.99, respectively. Of participants who underwent colonoscopy, five (1.5%) experienced major colonoscopy-related complications, including bowel perforation and major bleeding. CONCLUSIONS FIT appears to be an accurate screening test for patients with CKD, such that a negative test may rule out the diagnosis of colorectal cancer within 2 years. However, the risk of major complications from work-up colonoscopy are at least ten-fold higher than in the general population.
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Affiliation(s)
- Germaine Wong
- Sydney School of Public Health, Faculty of Medicine and Health, .,Centre for Transplant and Renal Research, and.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Richard L Hope
- Department of Gastroenterology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Kirsten Howard
- Sydney School of Public Health, Faculty of Medicine and Health
| | | | - Antoni Castells
- Gastroenterology Department, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain.,August Pi i Sunyer Biomedical Research Institute, Barcelona, Spain; and.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Spain
| | - Simon D Roger
- Department of Renal Medicine, Gosford Hospital, Gosford, Australia
| | - Michael J Bourke
- Department of Gastroenterology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Petra Macaskill
- Sydney School of Public Health, Faculty of Medicine and Health
| | - Robin Turner
- Sydney School of Public Health, Faculty of Medicine and Health.,Biostatistics Unit, Dunedin School of Medicine, University of Otago, Christchurch, New Zealand
| | - Gabrielle Williams
- Sydney School of Public Health, Faculty of Medicine and Health.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Wai Hon Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Australia
| | - Charmaine E Lok
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Australia
| | - Fritz Diekmann
- Department of Nephrology and Kidney Transplantation, Clinical and Provincial Hospital of Barcelona, Barcelona, Spain
| | - Nicholas B Cross
- Department of Nephrology and Kidney Transplantation, Christchurch Hospital, Christchurch, New Zealand.,Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Shaundeep Sen
- Department of Renal Medicine, Concord Repatriation General Hospital, Concord, Australia
| | - Richard D M Allen
- Department of Renal Medicine, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Steven J Chadban
- Department of Renal Medicine, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Charles Perkins Centre, The University of Sydney, Sydney, Australia
| | - Carol A Pollock
- Department of Medicine, Northern Clinical School, Kolling Institute of Medical Research, St Leonards, New South Wales, Australia
| | - Allison Tong
- Sydney School of Public Health, Faculty of Medicine and Health.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Armando Teixeira-Pinto
- Sydney School of Public Health, Faculty of Medicine and Health.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | | | - Narelle Williams
- Sydney School of Public Health, Faculty of Medicine and Health.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Eric Hoi Kit Au
- Sydney School of Public Health, Faculty of Medicine and Health.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Anh Kieu
- Sydney School of Public Health, Faculty of Medicine and Health.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Laura James
- Sydney School of Public Health, Faculty of Medicine and Health.,Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Jonathan C Craig
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
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23
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Au EH, Chapman JR, Craig JC, Lim WH, Teixeira-Pinto A, Ullah S, McDonald S, Wong G. Overall and Site-Specific Cancer Mortality in Patients on Dialysis and after Kidney Transplant. J Am Soc Nephrol 2019; 30:471-480. [PMID: 30765426 PMCID: PMC6405152 DOI: 10.1681/asn.2018090906] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Accepted: 12/29/2018] [Indexed: 01/13/2023] Open
Abstract
Background Patients with ESRD have a substantially increased cancer risk, but few studies have examined the patterns of cancer mortality along a patient's journey from dialysis to transplantation. METHODS We identified all Australian patients on dialysis and patients with transplants from 1980 to 2014 from the Australia and New Zealand Dialysis and Transplant Registry. Using standardized mortality ratios (SMRs), we compared cancer mortality among patients on dialysis and patients with transplants versus the general population (overall and by age, sex, year, and site); we also performed a subgroup analysis excluding patients with preexisting cancers. RESULTS We followed 52,936 patients on dialysis and 16,820 transplant recipients for 170,055 and 128,352 patient-years, respectively. There were 2739 cancer deaths among patients on dialysis and 923 cancer deaths among transplant recipients. Overall, cancer SMRs were 2.6 for patients on dialysis and 2.7 for transplant recipients. For patients on dialysis, SMRs were highest for multiple myeloma (30.5), testicular cancer (17.0), and kidney cancer (12.5); for transplant recipients, SMRs were highest for non-Hodgkin lymphoma (10.7), kidney cancer (7.8), and melanoma (5.8). Some 61.0% of patients on dialysis and 9.6% of transplant recipients who experienced cancer death had preexisting cancer. The SMRs for de novo cancer was 1.2 for patients on dialysis and 2.6 for transplant recipients. CONCLUSIONS Patients on dialysis and transplant recipients experienced >2.5-fold increased risk of cancer death compared with the general population. This increased risk was largely driven by preexisting cancers in patients on dialysis and de novo cancers in patients with transplants.
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Affiliation(s)
- Eric H. Au
- School of Public Health, University of Sydney, Sydney, Australia;,Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney, Australia;,Centre for Transplant and Renal Research, Westmead Hospital, Sydney, Australia
| | - Jeremy R. Chapman
- Centre for Transplant and Renal Research, Westmead Hospital, Sydney, Australia
| | - Jonathan C. Craig
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Wai H. Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Australia
| | - Armando Teixeira-Pinto
- School of Public Health, University of Sydney, Sydney, Australia;,Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney, Australia
| | - Shahid Ullah
- Australia and New Zealand Dialysis and Transplant Registry, South Australian Health and Medical Research Institute, Adelaide, Australia; and,Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - Stephen McDonald
- Australia and New Zealand Dialysis and Transplant Registry, South Australian Health and Medical Research Institute, Adelaide, Australia; and,Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - Germaine Wong
- School of Public Health, University of Sydney, Sydney, Australia;,Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney, Australia;,Centre for Transplant and Renal Research, Westmead Hospital, Sydney, Australia
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24
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Affiliation(s)
- Jeremy R Chapman
- Renal and Transplant UnitWestmead Hospital, NSW 2145 and Tissue Typing Laboratory, Red Cross Blood Transfusion Service153 Clarence StreetSydney, NSW 2000
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25
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Nankivell BJ, P'Ng CH, Chapman JR. Does tubulitis without interstitial inflammation represent borderline acute T cell mediated rejection? Am J Transplant 2019; 19:132-144. [PMID: 29687946 DOI: 10.1111/ajt.14888] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 03/30/2018] [Accepted: 03/31/2018] [Indexed: 01/25/2023]
Abstract
Tubulitis without interstitial inflammation (Banff i0), termed "isolated tubulitis" (ISO-T), has been controversially included within the Banff "borderline" category of acute T cell mediated rejection (TCMR). This single-center, retrospective, observational study of 2055 consecutive biopsies from 775 recipients, determined the clinical significance of ISO-T. ISO-T prevalence was 19.1%, comprising mild tubulitis (i0t1) in 97.2%. Independent clinical predictors of tubulitis were HLA mismatch, prior TCMR and antibody-mediated rejection, pulse corticosteroids, and BKVAN (P = .006 to P < .001 by multivariable analysis). Histological associations of tubulitis included interstitial inflammation, peritubular capillaritis, tubular atrophy, and SV40T (P = .005 to <.001). The dominant pathological diagnoses in ISO-T (n = 393) were interstitial fibrosis/tubular atrophy (IF/TA, 44.5%) or normal/minimal (31.8%). Subanalysis of ISO-T from indication biopsies (n = 107) found acute tubular injury (37.4%), IF/TA (28.0%), normal/minimal (12.1%), acute rejection (9.3%, vascular or antibody), chronic-active TCMR (2.8%), and BKVAN (5.6%). Allograft function of ISO-T frequently improved, affected by early biopsy timing and underlying disease diagnosis. Subsequent histology of 1197 ISO-T biopsy-pairs was generally benign. The 1- and 5-year death-censored graft survivals of ISO-T were 98.8% and 92.7%. In summary, tubulitis without inflammation does not represent borderline TCMR. We suggest its removal from the borderline category, and reinstatement of i1 as the diagnostic threshold.
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Affiliation(s)
| | - Chow H P'Ng
- Tissue Pathology and Diagnostic Oncology, ICPMR, Sydney, Australia
| | - Jeremy R Chapman
- Departments of Renal Medicine, Westmead Hospital, Sydney, Australia
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26
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Chan S, Ng S, Chan HP, Pascoe E, Playford EG, Wong G, Chapman JR, Lim WH, Francis RS, Isbel NM, Campbell SB, Hawley CM, Johnson DW. Perioperative antibiotics for preventing post-surgical site infections in solid organ transplant recipients. Hippokratia 2018. [DOI: 10.1002/14651858.cd013209] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Samuel Chan
- Princess Alexandra Hospital; Department of Nephrology; Ipswich Road, Woolloongabba Brisbane Queensland Australia 4102
| | - Samantha Ng
- Princess Alexandra Hospital; Department of Nephrology; Ipswich Road, Woolloongabba Brisbane Queensland Australia 4102
| | - Hooi P Chan
- General Practice Queensland; Brisbane Queensland Australia 4102
| | - Elaine Pascoe
- The University of Queensland; Department of Biostatistics, Faculty of Medicine; Brisbane Queensland Australia 4102
| | - Elliott Geoffrey Playford
- Princess Alexandra Hospital; Department of Infection Control Management; 199 Ipswich Road Woolloongabba Queensland Australia 4102
| | - Germaine Wong
- The University of Sydney; School of Public Health; Sydney NSW Australia 2006
| | - Jeremy R Chapman
- Westmead Clinical School; Department of Nephrology; Sydney NSW Australia 2006
| | - Wai H Lim
- Sir Charles Gardiner Hospital; Department of Nephrology; Perth Western Australia Australia 6009
| | - Ross S Francis
- Princess Alexandra Hospital; Department of Nephrology; Ipswich Road, Woolloongabba Brisbane Queensland Australia 4102
| | - Nicole M Isbel
- Princess Alexandra Hospital; Department of Nephrology; Ipswich Road, Woolloongabba Brisbane Queensland Australia 4102
| | - Scott B Campbell
- Princess Alexandra Hospital; Department of Nephrology; Ipswich Road, Woolloongabba Brisbane Queensland Australia 4102
| | - Carmel M Hawley
- Princess Alexandra Hospital; Department of Nephrology; Ipswich Road, Woolloongabba Brisbane Queensland Australia 4102
| | - David W Johnson
- Princess Alexandra Hospital; Department of Nephrology; Ipswich Road, Woolloongabba Brisbane Queensland Australia 4102
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27
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Lim WH, Coates PT, Russ GR, Russell C, He B, Jaques B, Pleass H, Chapman JR, Wong G. Weekend effect on early allograft outcome after kidney transplantation- a multi-centre cohort study. Transpl Int 2018; 32:387-398. [PMID: 30427079 DOI: 10.1111/tri.13377] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 06/20/2018] [Accepted: 11/08/2018] [Indexed: 11/27/2022]
Abstract
Weekend surgery may be associated with a higher risk of early complications, but the effect of the timing of kidney transplant surgery on early allograft outcome remains uncertain. The aim of this study is to evaluate whether the association between weekend transplant surgery and allograft failure was modified by prevalent vascular disease. Using data from the Australia and New Zealand Dialysis and Transplant registry, we examined the association between weekend status and 90-day and 1-year allograft failure in deceased donor transplant recipients between 1994-2012. Two-way interaction between vascular disease and weekend status was examined. Of 6622 recipients, 1868 (28.2%) received transplants during weekends. Compared with weekday transplants, weekend transplants were associated with an adjusted hazard ratio (HR) for 90-day and 1-year allograft failure of 0.99 (0.78-1.25; P = 0.917) and 0.93 (0.76-1.13, P = 0.468), respectively. There was a significant interaction between prevalent vascular disease and weekend status for 90-day allograft failure (Pinteraction = 0.008) but not at 1-year, such that patients with vascular disease were more likely to experience 90-day allograft failure if transplanted on weekend (versus weekdays), particularly failures secondary to vascular complications. Timing of transplantation does not impact on allograft outcome, although those with vascular disease may benefit from more intensive post-transplant follow-up for potential vascular complications.
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Affiliation(s)
- Wai H Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia.,School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia.,Australia and New Zealand Dialysis and Transplant Registry, Adelaide, SA, Australia
| | - Patrick T Coates
- Central and Northern Adelaide Renal and Transplantation Services, Adelaide, SA, Australia
| | - Graeme R Russ
- Australia and New Zealand Dialysis and Transplant Registry, Adelaide, SA, Australia.,Central and Northern Adelaide Renal and Transplantation Services, Adelaide, SA, Australia
| | - Christine Russell
- Central and Northern Adelaide Renal and Transplantation Services, Adelaide, SA, Australia
| | - Bulang He
- Western Australia Kidney and Liver Transplant Service, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Bryon Jaques
- Western Australia Kidney and Liver Transplant Service, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Henry Pleass
- University of Sydney, Sydney, NSW, Australia.,Centre for Transplant and Renal Research, Westmead Hospital, Sydney, NSW, Australia
| | - Jeremy R Chapman
- University of Sydney, Sydney, NSW, Australia.,Centre for Transplant and Renal Research, Westmead Hospital, Sydney, NSW, Australia
| | - Germaine Wong
- Centre for Transplant and Renal Research, Westmead Hospital, Sydney, NSW, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia.,Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
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28
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Chapman JR, Kanellis J. Kidney donation and transplantation in Australia: more than a supply and demand equation. Med J Aust 2018; 209:242-243. [DOI: 10.5694/mja18.00617] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 07/24/2018] [Indexed: 11/17/2022]
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29
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Calisa V, Craig JC, Howard K, Howell M, Alexander S, Chadban SJ, Clayton P, Lim WH, Kanellis J, Wyburn K, Johnson DW, McDonald SP, Opdam H, Chapman JR, Yang J, Wong G. Survival and Quality of Life Impact of a Risk-based Allocation Algorithm for Deceased Donor Kidney Transplantation. Transplantation 2018; 102:1530-1537. [DOI: 10.1097/tp.0000000000002144] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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30
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Hanson CS, Chapman JR, Gill JS, Kanellis J, Wong G, Craig JC, Teixeira-Pinto A, Chadban SJ, Garg AX, Ralph AF, Pinter J, Lewis JR, Tong A. Identifying Outcomes that Are Important to Living Kidney Donors: A Nominal Group Technique Study. Clin J Am Soc Nephrol 2018; 13:916-926. [PMID: 29853616 PMCID: PMC5989678 DOI: 10.2215/cjn.13441217] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Accepted: 03/14/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Living kidney donor candidates accept a range of risks and benefits when they decide to proceed with nephrectomy. Informed consent around this decision assumes they receive reliable data about outcomes they regard as critical to their decision making. We identified the outcomes most important to living kidney donors and described the reasons for their choices. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Previous donors were purposively sampled from three transplant units in Australia (Sydney and Melbourne) and Canada (Vancouver). In focus groups using the nominal group technique, participants identified outcomes of donation, ranked them in order of importance, and discussed the reasons for their preferences. An importance score was calculated for each outcome. Qualitative data were analyzed thematically. RESULTS Across 14 groups, 123 donors aged 27-78 years identified 35 outcomes. Across all participants, the ten highest ranked outcomes were kidney function (importance=0.40, scale 0-1), time to recovery (0.27), surgical complications (0.24), effect on family (0.22), donor-recipient relationship (0.21), life satisfaction (0.18), lifestyle restrictions (0.18), kidney failure (0.14), mortality (0.13), and acute pain/discomfort (0.12). Kidney function and kidney failure were more important to Canadian participants, compared with Australian donors. The themes identified included worthwhile sacrifice, insignificance of risks and harms, confidence and empowerment, unfulfilled expectations, and heightened susceptibility. CONCLUSIONS Living kidney donors prioritized a range of outcomes, with the most important being kidney health and the surgical, lifestyle, functional, and psychosocial effects of donation. Donors also valued improvements to their family life and donor-recipient relationship. There were clear regional differences in the rankings.
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Affiliation(s)
- Camilla S. Hanson
- Sydney School of Public Health and
- Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia
| | - Jeremy R. Chapman
- Centre for Transplant and Renal Research, Westmead Institute for Medical Research, The University of Sydney, Westmead, New South Wales, Australia
| | - John S. Gill
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - John Kanellis
- Department of Nephrology, Monash Health and Centre for Inflammatory Diseases, Department of Medicine, Monash University, Clayton, Victoria, Australia
| | - Germaine Wong
- Sydney School of Public Health and
- Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia
- Centre for Transplant and Renal Research, Westmead Institute for Medical Research, The University of Sydney, Westmead, New South Wales, Australia
| | - Jonathan C. Craig
- Sydney School of Public Health and
- Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia
| | - Armando Teixeira-Pinto
- Sydney School of Public Health and
- Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia
| | - Steve J. Chadban
- Kidney Node, Charles Perkins Centre, The University of Sydney, Sydney, New South Wales, Australia
- Renal Medicine, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Amit X. Garg
- Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada; and
| | - Angelique F. Ralph
- Sydney School of Public Health and
- Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia
| | - Jule Pinter
- Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia
- Division of Nephrology, Department of Medicine, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Joshua R. Lewis
- Sydney School of Public Health and
- Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia
| | - Allison Tong
- Sydney School of Public Health and
- Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia
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Abstract
Increasingly, obese and overweight but healthy individuals are being considered for living donation, but the consequences of obesity on long-term health outcomes, including the risk of progression to end-stage kidney disease after donor nephrectomy, are relatively unknown. In this issue, Locke et al. analyzed a large cohort of living kidney donors in the United States, including 26% who were obese, and estimated the attributable and relative risk of end-stage kidney disease over time. Findings from this study challenge the current recommended thresholds for obesity that usually preclude donation, and inform communication regarding risk between clinicians and prospective donors during the donor evaluation process.
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Affiliation(s)
- Germaine Wong
- Centre for Transplant and Renal Research, Westmead Hospital, Westmead, Australia; Sydney School of Public Health, University of Sydney, Sydney, Australia.
| | - Jonathan C Craig
- Sydney School of Public Health, University of Sydney, Sydney, Australia
| | - Jeremy R Chapman
- Centre for Transplant and Renal Research, Westmead Hospital, Westmead, Australia
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Sharma A, Lewis JR, Lim WH, Palmer S, Strippoli G, Chapman JR, Alexander SI, Craig JC, Wong G. Renal transplant outcomes and de novo donor-specific anti-human leukocyte antigen antibodies: a systematic review. Nephrol Dial Transplant 2018; 33:1472-1480. [DOI: 10.1093/ndt/gfy077] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 02/09/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Ankit Sharma
- Centre for Kidney Research, Children’s Hospital at Westmead, Westmead, Australia
- School of Public Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Joshua R Lewis
- Centre for Kidney Research, Children’s Hospital at Westmead, Westmead, Australia
- School of Public Health, Sydney Medical School, University of Sydney, Sydney, Australia
- School of Medicine and Pharmacology, The University of Western Australia, Perth, Australia
| | - Wai H Lim
- School of Medicine and Pharmacology, The University of Western Australia, Perth, Australia
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Australia
| | - Suetonia Palmer
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Giovanni Strippoli
- Centre for Kidney Research, Children’s Hospital at Westmead, Westmead, Australia
| | - Jeremy R Chapman
- Centre for Transplant and Renal Research, Westmead Hospital, Westmead, Australia
| | - Stephen I Alexander
- Centre for Kidney Research, Children’s Hospital at Westmead, Westmead, Australia
| | - Jonathan C Craig
- Centre for Kidney Research, Children’s Hospital at Westmead, Westmead, Australia
- School of Public Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Germaine Wong
- Centre for Kidney Research, Children’s Hospital at Westmead, Westmead, Australia
- School of Public Health, Sydney Medical School, University of Sydney, Sydney, Australia
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Nankivell BJ, Shingde M, Keung KL, Fung CLS, Borrows RJ, O'Connell PJ, Chapman JR. The causes, significance and consequences of inflammatory fibrosis in kidney transplantation: The Banff i-IFTA lesion. Am J Transplant 2018; 18:364-376. [PMID: 29194971 DOI: 10.1111/ajt.14609] [Citation(s) in RCA: 88] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 10/25/2017] [Accepted: 10/28/2017] [Indexed: 01/25/2023]
Abstract
Inflammation within areas of interstitial fibrosis and tubular atrophy (i-IFTA) is associated with adverse outcomes in kidney transplantation. We evaluated i-IFTA in 429 indication- and 2052 protocol-driven biopsy samples from a longitudinal cohort of 362 kidney-pancreas recipients to determine its prevalence, time course, and relationships with T cell-mediated rejection (TCMR), immunosuppression, and outcome. Sequential histology demonstrated that i-IFTA was preceded by cellular interstitial inflammation and followed by IF/TA. The prevalence and intensity of i-IFTA increased with developing chronic fibrosis and correlated with inflammation, tubulitis, and immunosuppression era (P < .001). Tacrolimus era-based immunosuppression was associated with reduced histologic inflammation in unscarred and scarred i-IFTA compartments, ameliorated progression of IF, and increased conversion to inactive IF/TA (compared with cyclosporine era, P < .001). Prior acute (including borderline) TCMR and subclinical TCMR were followed by greater 1-year i-IFTA, remaining predictive by multivariate analysis and independent of humoral markers. One-year i-IFTA was associated with accelerated IF/TA, arterial fibrointimal hyperplasia, and chronic glomerulopathy and with reduced renal function (P < .001 versus no i-IFTA). In summary, i-IFTA is the histologic consequence of active T cell-mediated alloimmunity, representing the interface between inflammation and tubular injury with fibrotic healing. Uncontrolled i-IFTA is associated with adverse structural and functional outcomes.
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Affiliation(s)
| | - Meena Shingde
- Tissue Pathology and Diagnostic Oncology, Westmead Hospital, Sydney, Australia
| | - Karen L Keung
- Department of Renal Medicine, Westmead Hospital, Sydney, Australia
| | - Caroline L-S Fung
- Tissue Pathology and Diagnostic Oncology, Westmead Hospital, Sydney, Australia
| | | | | | - Jeremy R Chapman
- Department of Renal Medicine, Westmead Hospital, Sydney, Australia
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Hanson CS, Ralph AF, Manera KE, Gill JS, Kanellis J, Wong G, Craig JC, Chapman JR, Tong A. The Lived Experience of "Being Evaluated" for Organ Donation: Focus Groups with Living Kidney Donors. Clin J Am Soc Nephrol 2017; 12:1852-1861. [PMID: 28993303 PMCID: PMC5672970 DOI: 10.2215/cjn.03550417] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Accepted: 07/17/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND OBJECTIVES Comprehensive evaluations are required to safeguard voluntarism and minimize harm to living kidney donors. This process is lengthy, invasive, and emotionally challenging, with up to one fifth of potential donors opting out. We aimed to describe donors' experiences of the evaluation process. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted 14 focus groups involving 123 kidney donors who completed donation from three transplant centers (Australia and Canada). Transcripts were analyzed thematically. RESULTS We identified six themes reflecting donors' experiences of evaluation. The themes that related to perseverance included emotional investment (prioritizing the recipient's health, desperation for a normal life, protecting eligibility, shame of disappointing others, and overcoming opposition), undeterred by low risks (medical confidence and protection, worthwhile gamble, inherent invincibility, and normalizing risks), and mental preparation (avoiding regret, resolving decisional ambivalence, and managing expectations of recovery). The challenges included underlying fears for health (processing alarming information, unsettling uncertainty, and preoperative panic), system shortfalls (self-advocacy in driving the process, stressful urgency, inconsistent framing of safety, unnerving bodily scrutiny, questioning risk information, and draining finances); and lifestyle interference (living in limbo, onerous lifestyle disruption, and valuing flexibility). CONCLUSIONS Previous donors described an emotional investment in donating and determination to protect their eligibility, despite having concerns for their health, financial and lifestyle disruption, and opposition from their family or community. Our findings suggest the need to prepare donors for surgery and recovery, minimize anxiety and lifestyle burdens, ensure that donors feel comfortable expressing their fears and concerns, reduce unnecessary delays, and make explicit the responsibilities of donors in their assessment process.
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Affiliation(s)
- Camilla S. Hanson
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
| | - Angelique F. Ralph
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
| | - Karine E. Manera
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
| | - John S. Gill
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - John Kanellis
- Department of Nephrology, Monash Health and Centre for Inflammatory Diseases, Department of Medicine, Monash University, Clayton, Victoria, Australia; and
| | - Germaine Wong
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
- Centre for Transplant and Renal Research, The Westmead Institute for Medical Research, Westmead, New South Wales, Australia
| | - Jonathan C. Craig
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
| | - Jeremy R. Chapman
- Centre for Transplant and Renal Research, The Westmead Institute for Medical Research, Westmead, New South Wales, Australia
| | - Allison Tong
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
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Fisher M, Chapman JR, Ting A, Morris PJ. Alloimmunisation to HLA Antigens following Transfusion
with Leucocyte-Poor and Purified Platelet Suspensions. Vox Sang 2017. [DOI: 10.1159/000466401] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Nankivell BJ, Renthawa J, Sharma RN, Kable K, O'Connell PJ, Chapman JR. BK Virus Nephropathy: Histological Evolution by Sequential Pathology. Am J Transplant 2017; 17:2065-2077. [PMID: 28371308 DOI: 10.1111/ajt.14292] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Revised: 03/09/2017] [Accepted: 03/18/2017] [Indexed: 01/25/2023]
Abstract
Reactivation of BK virus in renal allografts causes a destructive chronic infection. This single-center retrospective cohort study describes the evolution of BK virus allograft nephropathy (BKVAN) from 63 kidneys (from 61 patients) using sequential histopathology (454 biopsies, averaging 7.8 ± 2.6 per kidney) followed for 60.1 mo. Uninfected protocol biopsies formulated time-matched control Banff scores (n = 975). Interstitial inflammation occurred in 73% at diagnosis, correlating with viral histopathology (r = 0.413, p = 0.008) and amplifying early injury with accelerated interstitial fibrosis and tubular atrophy (IF/TA, p = 0.017) by 3 mo. Prodromal simian virus 40 large T antigen (SV40T)-negative inflammation with viremia preceded the histological diagnosis in 23.8%. Persistent subacute injury from viral cytopathic effect was associated with acute tubular necrosis and ongoing interstitial inflammation, culminating in IF/TA in 86.9%. Overall, cellular interstitial infiltration mitigated the intensity of subsequent tubular injury, SV40T, and tissue viral load, assessed by sequential paired histology (p < 0.001). Graft loss was predicted by high-level viremia (hazard ratio [HR] 4.996, 95% CI 2.19-11.396, p < 0.001), deceased donor (HR 3.201, 95% CI 1.149-8.915, p = 0.026), and late acute rejection (HR 3.124, 95% CI 1.037-9.413, p = 0.043). Transplant failure occurred in 38.1%, with uncontrolled infection (58.3%) and SV40T-negative chronic rejection (41.7%) causing losses. BKVAN is characterized by subacute virus-induced tubular injury, inflammation, and progressive nephron destruction. Effective antiviral therapy remains an unmet clinical need.
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Affiliation(s)
- B J Nankivell
- Department of Renal Medicine, Westmead Hospital, Westmead, Australia
| | - J Renthawa
- Department of Tissue Pathology and Diagnostic Oncology, ICPMR, Sydney, Australia
| | - R N Sharma
- Department of Tissue Pathology and Diagnostic Oncology, ICPMR, Sydney, Australia
| | - K Kable
- Department of Renal Medicine, Westmead Hospital, Westmead, Australia
| | - P J O'Connell
- Department of Renal Medicine, Westmead Hospital, Westmead, Australia
| | - J R Chapman
- Department of Renal Medicine, Westmead Hospital, Westmead, Australia
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Webster AC, Wu S, Tallapragada K, Park MY, Chapman JR, Carr SJ. Polyclonal and monoclonal antibodies for treating acute rejection episodes in kidney transplant recipients. Cochrane Database Syst Rev 2017; 7:CD004756. [PMID: 28731207 PMCID: PMC6483358 DOI: 10.1002/14651858.cd004756.pub4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Registry data shows that the incidence of acute rejection has been steadily falling. Approximately 10% to 35% of kidney recipients will undergo treatment for at least one episode of acute rejection within the first post-transplant year. Treatment options include pulsed steroid therapy, the use of an antibody preparation, the alteration of background immunosuppression, or combinations of these options. Over recent years, new treatment strategies have evolved, and in many parts of the world there has been an increase in use of tacrolimus and mycophenolate and a reduction in the use of cyclosporin and azathioprine use as baseline immunosuppression to prevent acute rejection. There are also global variations in use of polyclonal and monoclonal antibodies to treat acute rejection. This is an update of a review published in 2006. OBJECTIVES The aim of this systematic review was to: (1) to evaluate the relative and absolute effects of different classes of antibody preparation in preventing graft loss and resolving cellular or humoral rejection episodes when used as a treatment for first episode of rejection in kidney transplant recipients; (2) evaluate the relative and absolute effects of different classes of antibody preparation in preventing graft loss and resolving cellular or humoral rejection episodes when used as a treatment for steroid-resistant rejection in kidney transplant recipients; (3) determine how the benefits and adverse events vary for each type of antibody preparation; and (4) determine how the benefits and harms vary for different formulations of antibody within each type. SEARCH METHODS We searched the Cochrane Kidney and Transplant Specialised Register to 18 April 2017 through contact with the Information Specialist using search terms relevant to this review. SELECTION CRITERIA Randomised controlled trials (RCTs) in all languages comparing all mono- and polyclonal antibody preparations, given in combination with any other immunosuppressive agents, for the treatment of cellular or humoral graft rejection, when compared to any other treatment for acute rejection were eligible for inclusion. DATA COLLECTION AND ANALYSIS Two authors independently assessed the risk of bias of the included studies and extracted data. Statistical analyses were performed using a random-effects model and results expressed as risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI). MAIN RESULTS We included 11 new studies (18 reports, 346 participants) in this update, bring the total number of included studies to 31 (76 reports, 1680 participants). Studies were generally small, incompletely reported, especially for potential harms, and did not define outcome measures adequately. The risk of bias was inadequate or unclear risk for random sequence generation (81%), allocation concealment (87%) and other bias (87%). There were, however, a predominance of low risk of bias for blinding (75%) and incomplete outcome data (80%) across all the studies. Selective reporting had a mixture of low (58%), high (29%), and unclear (13%) risk of bias.Seventeen studies (1005 participants) compared therapies for first acute cellular rejection episodes. Antibody therapy was probably better than steroid in reversing acute cellular rejection (RR 0.50, 95% CI 0.30 to 0.82; moderate certainty) and preventing subsequent rejection (RR 0.70, 95% CI 0.50 to 0.99; moderate certainty), may be better for preventing graft loss (death censored: (RR 0.80, 95% CI 0.57 to 1.12; low certainty) but there was little or no difference in death at one year. Adverse effects of treatment (including fever, chills and malaise following drug administration) were probably reduced with steroid therapy (RR 23.88, 95% CI 5.10 to 111.86; I2 = 16%; moderate certainty).Twelve studies (576 patients) investigated antibody treatment for steroid-resistant rejection. There was little or no benefit of muromonab-CD3 over ATG or ALG in reversing rejection, preventing subsequent rejection, or preventing graft loss or death. Two studies compared the use of rituximab for treatment of acute humoral rejection (58 patients). Muromonab-CD3 treated patients suffered three times more than those receiving either ATG or T10B9, from a syndrome of fever, chills and malaise following drug administration (RR 3.12, 95% CI 1.87 to 5.21; I2 = 31%), and experienced more neurological side effects (RR 13.10 95% CI 1.43 to 120.05; I2 = 36%) (low certainty evidence).There was no evidence of additional benefit from rituximab in terms of either reversal of rejection (RR 0.94, 95% CI 0.54 to 1.64), or graft loss or death 12 months (RR 1.0, 95% CI 0.23 to 4.35). Rituximab plus steroids probably increases the risk of urinary tract infection/pyelonephritis (RR 5.73, 95% CI 1.80 to 18.21). AUTHORS' CONCLUSIONS In reversing first acute cellular rejection and preventing graft loss, any antibody is probably better than steroid, but there is little or no difference in subsequent rejection and patient survival. In reversing steroid-resistant rejection there was little or no difference between different antibodies over a period of 12 months, with limited data beyond that time frame. In treating acute humoral rejection, there was no evidence that the use of antibody therapy conferred additional benefit in terms of reversal of rejection, or death or graft loss.Although this is an updated review, the majority of newer included studies provide additional evidence from the cyclosporin/azathioprine era of kidney transplantation and therefore conclusions cannot necessarily be extrapolated to patients treated with more contemporary immunosuppressive regimens which include tacrolimus/mycophenolate or sirolimus. However, many kidney transplant centres around the world continue to use older immunosuppressive regimes and the findings of this review remain strongly relevant to their clinical practice.Larger studies with standardised reproducible outcome criteria are needed to investigate the outcomes and risks of antibody treatments for acute rejection in kidney transplant recipients receiving contemporary immunosuppressive regimes.
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Affiliation(s)
- Angela C Webster
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
- The University of Sydney at WestmeadCentre for Transplant and Renal Research, Westmead Millennium InstituteWestmeadNSWAustralia2145
| | - Sunny Wu
- The Children's Hospital at WestmeadCentre for Kidney ResearchCorner Hawkesbury and Darcy RoadsWestmeadNSWAustralia2145
| | - Krishna Tallapragada
- The Children's Hospital at WestmeadCentre for Kidney ResearchCorner Hawkesbury and Darcy RoadsWestmeadNSWAustralia2145
| | - Min Young Park
- The Children's Hospital at WestmeadCentre for Kidney ResearchCorner Hawkesbury and Darcy RoadsWestmeadNSWAustralia2145
| | - Jeremy R Chapman
- Westmead Millennium Institute, The University of Sydney at WestmeadCentre for Transplant and Renal ResearchDarcy RdWestmeadNSWAustralia2145
| | - Sue J Carr
- University Hospitals of LeicesterRenal DepartmentGwendolen RdLeicesterUKLE5 4PW
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Hanson CS, Chapman JR, Craig JC, Harris DC, Kairaitis LK, Nicdao M, Mikaheal M, Tong A. Patient experiences of training and transition to home haemodialysis: A mixed-methods study. Nephrology (Carlton) 2017; 22:631-641. [DOI: 10.1111/nep.12827] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 05/23/2016] [Accepted: 05/24/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Camilla S Hanson
- Sydney School of Public Health; The University of Sydney; Sydney New South Wales Australia
- Centre for Kidney Research; The Children's Hospital at Westmead; Sydney New South Wales Australia
| | - Jeremy R Chapman
- Centre for Transplant and Renal Research, The Westmead Institute for Medical Research; The University of Sydney; Sydney New South Wales Australia
| | - Jonathan C Craig
- Sydney School of Public Health; The University of Sydney; Sydney New South Wales Australia
- Centre for Kidney Research; The Children's Hospital at Westmead; Sydney New South Wales Australia
| | - David C Harris
- Centre for Transplant and Renal Research, The Westmead Institute for Medical Research; The University of Sydney; Sydney New South Wales Australia
| | - Lukas K Kairaitis
- Department of Renal Medicine; Westmead Hospital; Sydney New South Wales Australia
- School of Medicine; Western Sydney University; Sydney New South Wales Australia
| | - Maryann Nicdao
- Department of Renal Medicine; Westmead Hospital; Sydney New South Wales Australia
| | - Mary Mikaheal
- Department of Renal Medicine; Westmead Hospital; Sydney New South Wales Australia
| | - Allison Tong
- Sydney School of Public Health; The University of Sydney; Sydney New South Wales Australia
- Centre for Kidney Research; The Children's Hospital at Westmead; Sydney New South Wales Australia
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39
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Pinter J, Hanson CS, Chapman JR, Wong G, Craig JC, Schell JO, Tong A. Perspectives of Older Kidney Transplant Recipients on Kidney Transplantation. Clin J Am Soc Nephrol 2017; 12:443-453. [PMID: 28143863 PMCID: PMC5338704 DOI: 10.2215/cjn.05890616] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Accepted: 11/02/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Older kidney transplant recipients are susceptible to cognitive impairment, frailty, comorbidities, immunosuppression-related complications, and chronic graft failure, however, there has been limited focus on their concerns and expectations related to transplantation. This study aims to describe the perspectives of older kidney transplant recipients about their experience of kidney transplantation, self-management, and treatment goals to inform strategies and interventions that address their specific needs. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Face-to-face semistructured interviews were conducted with 30 kidney transplant recipients aged 65-80 years from five renal units in Australia. Transcripts were analyzed thematically. RESULTS Six themes were identified: restoring vitality of youth (with subthemes of revived mindset for resilience, embracing enjoyment in life, drive for self-actualization); persisting through prolonged recovery (yielding to aging, accepting functional limitations, pushing the limit, enduring treatment responsibilities); imposing sicknesses (combatting devastating comorbidities, painful restrictions, emerging disillusionment, anxieties about accumulating side effects, consuming treatment burden); prioritizing graft survival (privileged with a miracle, negotiating risks for longevity, enacting a moral duty, preserving the last opportunity); confronting health deterioration (vulnerability and helplessness, narrowing focus to immediate concerns, uncertainty of survival); and value of existence (purpose through autonomy, refusing the burden of futile treatment, staying alive by all means). CONCLUSIONS Older kidney transplant recipients felt able to enjoy life and strived to live at their newly re-established potential and capability, which motivated them to protect their graft. However, some felt constrained by slow recuperation and overwhelmed by unexpected comorbidities, medication-related side effects, and health decline. Our findings suggest the need to prepare and support older recipients for self-management responsibilities, clarify their expectations of post-transplant risks and outcomes, and provide assistance through prolonged recovery after kidney transplantation.
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Affiliation(s)
- Jule Pinter
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
- Department of Medicine, Division of Nephrology, Würzburg University Clinic, Würzburg, Germany
| | - Camilla S. Hanson
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
| | - Jeremy R. Chapman
- Centre for Transplant and Renal Research, Westmead Hospital, Westmead, New South Wales, Australia; and
| | - Germaine Wong
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
- Centre for Transplant and Renal Research, Westmead Hospital, Westmead, New South Wales, Australia; and
| | - Jonathan C. Craig
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
| | - Jane O. Schell
- Section of Palliative Care and Medical Ethics, Renal-Electrolyte Division, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Allison Tong
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, New South Wales, Australia
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Tong A, Sautenet B, Chapman JR, Harper C, MacDonald P, Shackel N, Crowe S, Hanson C, Hill S, Synnot A, Craig JC. Research priority setting in organ transplantation: a systematic review. Transpl Int 2017; 30:327-343. [PMID: 28120462 DOI: 10.1111/tri.12924] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 01/16/2017] [Accepted: 01/19/2017] [Indexed: 02/06/2023]
Abstract
Barriers to access and long-term complications remain a challenge in transplantation. Further advancements may be achieved through research priority setting with patient engagement to strengthen its relevance. We evaluated research priority setting in solid organ transplantation and described stakeholder priorities. Databases were searched to October 2016. We synthesized the findings descriptively. The 28 studies (n = 2071 participants) addressed kidney [9 (32%)], heart [7 (25%)], liver [3 (11%)], lung [1 (4%)], pancreas [1 (4%)], and nonspecified organ transplantation [7 (25%)] using consensus conferences, expert panel meetings, workshops, surveys, focus groups, interviews, and the Delphi technique. Nine (32%) reported patient involvement. The 336 research priorities addressed the following: organ donation [43 priorities (14 studies)]; waitlisting and allocation [43 (10 studies)]; histocompatibility and immunology [31 (8 studies)]; immunosuppression [21 (10 studies)]; graft-related complications [38 (13 studies)]; recipient (non-graft-related) complications [86 (14 studies)]; reproduction [14 (1 study)], psychosocial and lifestyle [49 (7 studies)]; and disparities in access and outcomes [10 (4 studies)]. The priorities identified were broad but only one-third of initiatives engaged patients/caregivers, and details of the process were lacking. Setting research priorities in an explicit manner with patient involvement can guide investment toward the shared priorities of patients and health professionals.
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Affiliation(s)
- Allison Tong
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Benedicte Sautenet
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Jeremy R Chapman
- Centre for Transplant and Renal Research, Westmead Hospital, Sydney, NSW, Australia
| | - Claudia Harper
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Peter MacDonald
- Heart Transplant Unit, St Vincent's Hospital, Sydney, NSW, Australia.,Transplantation Research Laboratory, Victor Chang, Cardiac Research Institute, Sydney, NSW, Australia
| | - Nicholas Shackel
- Department of Medicine, University of New South Wales, Sydney, NSW, Australia
| | | | - Camilla Hanson
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Sophie Hill
- Centre for Health Communication and Participation, La Trobe University, Melbourne, Vic., Australia
| | - Anneliese Synnot
- Centre for Health Communication and Participation, La Trobe University, Melbourne, Vic., Australia.,School of Preventive Medicine and Public Health, Monash University, Melbourne, Vic., Australia
| | - Jonathan C Craig
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
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Wong G, Chakera A, Chapman JR, Chadban SC, Pilmore H, Craig JC, Lim WH. Cytomegalovirus and cancer after kidney transplantation: Role of the human leukocyte antigen system? Transpl Infect Dis 2016; 19. [PMID: 27860123 DOI: 10.1111/tid.12631] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Revised: 07/11/2016] [Accepted: 08/01/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND The role of cytomegalovirus (CMV) in cancer development after transplantation remains uncertain. We aimed to determine the association between donor and recipient CMV serological status and the risk of cancer development after kidney transplantation. METHODS Using data from the Australian and New Zealand Dialysis and Transplant (ANZDATA) Registry, we assessed the association between CMV donor/recipient (D/R) serological status and the risk of solid organ cancers in primary adult deceased-donor kidney transplant patients between 1990 and 2012. RESULTS Of 8140 recipients, a total of 895 (11%) recipients developed incident cancers during a follow-up time of 51 555 person-years. Human leukocyte antigen (HLA) mismatches was an effect modifier between CMV serological status and cancer (P=.03 for interaction). In recipients who have received 0-2 HLA-ABDR mismatched kidneys, the adjusted hazard ratios for cancer incidence among those with CMV D-/R-, CMV D-/R+, and CMV D+/R- were 0.47 (95% confidence interval [CI]: 0.24-0.91), 1.42 (95% CI: 0.97-2.07), and 1.02 (95% CI: 0.67-1.57), respectively compared with the reference of CMV D+/R+. A similar association was not observed in those with >2 HLA-ABDR mismatches. CONCLUSION CMV D-/R- status was associated with a reduced risk of cancer in kidney transplant recipients who have received well-matched renal allografts, suggesting a potential role of HLA matching in cancer development.
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Affiliation(s)
- Germaine Wong
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia.,Centre for Transplant and Renal Research, Westmead Hospital, Westmead, NSW, Australia
| | - Aron Chakera
- Renal Department, Sir Charles Gairdner Hospital, Nedlands, Western Australia School of Medicine and Pharmacology, University of Western Australia, Western Australia Harry Perkins Institute of Medical Research, Verdun St. Nedlands, WA, Australia
| | - Jeremy R Chapman
- Centre for Transplant and Renal Research, Westmead Hospital, Westmead, NSW, Australia
| | - Steve C Chadban
- Central Clinical School, Royal Prince Alfred Hospital, University of Sydney, Sydney, NSW, Australia
| | - Helen Pilmore
- Department of Renal Medicine, Auckland City Hospital and Department of Medicine, Auckland University, Auckland, New Zealand
| | - Jonathan C Craig
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Wai H Lim
- Renal Department, Sir Charles Gairdner Hospital, Nedlands, Western Australia School of Medicine and Pharmacology, University of Western Australia, Western Australia Harry Perkins Institute of Medical Research, Verdun St. Nedlands, WA, Australia
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42
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Ralph AF, Butow P, Hanson CS, Chadban SJ, Chapman JR, Craig JC, Kanellis J, Luxton G, Tong A. Donor and Recipient Views on Their Relationship in Living Kidney Donation: Thematic Synthesis of Qualitative Studies. Am J Kidney Dis 2016; 69:602-616. [PMID: 27889296 DOI: 10.1053/j.ajkd.2016.09.017] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 09/25/2016] [Indexed: 11/11/2022]
Abstract
BACKGROUND Many donors and recipients report an improved relationship after transplantation; however, tension, neglect, guilt, and proprietorial concern over the recipient can impede donor and recipient well-being and outcomes. We aimed to describe donor and recipient expectations and experiences of their relationship in the context of living kidney donation. STUDY DESIGN Thematic synthesis of qualitative studies. SETTING & POPULATION Living kidney donors and recipients. SEARCH STRATEGY & SOURCES Electronic databases were searched to October 2015. ANALYTICAL APPROACH Thematic synthesis. RESULTS From 40 studies involving 1,440 participants (889 donors and 551 recipients) from 13 countries, we identified 6 themes. "Burden of obligation" described the recipient's perpetual sense of duty to demonstrate gratitude to the donor. "Earning acceptance" was the expectation that donation would restore relationships. "Developing a unique connection" reflected the inexplicable bond that donor-recipient dyads developed postdonation. "Desiring attention" was expressed by donors who wanted recognition for the act of donation and were envious and resentful of the attention the recipient received. "Retaining kidney ownership" reflected the donor's inclination to ensure that the recipient protected "their" kidney. "Enhancing social participation" encompassed relieving both the caregiver from the constraints of dialysis and the recipient from increased involvement and contribution in family life. LIMITATIONS Non-English articles were excluded. CONCLUSIONS Living kidney donation can strengthen donor-recipient relationships but may trigger or exacerbate unresolved angst, tension, jealousy, and resentment. Facilitating access to pre- and posttransplantation psychological support that addresses potential relationship changes may help donors and recipients better adjust to changes in the relationship dynamics, which in turn may contribute to improved psychosocial and transplantation outcomes following living kidney donation.
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Affiliation(s)
- Angelique F Ralph
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia; School of Psychology, The University of Sydney, Sydney, NSW, Australia.
| | - Phyllis Butow
- School of Psychology, The University of Sydney, Sydney, NSW, Australia; Psycho-oncology Co-operative Research Group, The University of Sydney, Sydney, NSW, Australia; Centre for Medical Psychology & Evidence-based Decision-making, The University of Sydney, Sydney, NSW, Australia
| | - Camilla S Hanson
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Steve J Chadban
- Central Clinical School, The University of Sydney, Sydney, NSW, Australia; Transplantation Services, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Jeremy R Chapman
- Centre for Transplant and Renal Research, The University of Sydney, Westmead Hospital, Westmead, NSW, Australia
| | - Jonathan C Craig
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - John Kanellis
- Department of Nephrology, Monash Health and Centre for Inflammatory Diseases, Monash University, Clayton, VIC, Australia; Department of Medicine, Monash University, Clayton, VIC, Australia
| | - Grant Luxton
- Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Allison Tong
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia
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Abstract
A wish for progress in transplantation assumes that there are needs not met by the currently available therapy and that the barriers to resolving the problems can be surmounted. There are 5 major unmet needs: the potential to avoid transplantation either by prevention of disease or provision of an alternative to natural biological organ replacement; geographic heterogeneity of access to, and quality of, transplantation; availability of transplantation to those in need of it; survival of the patient and the transplant; and the avoidance of adverse effects of immunosuppression. During the past 50 years, there have been advances on at least 4 of these 5 fronts that illustrate the interplay of "big steps" and "marginal gains" in the following areas: surgical technique, testing the immunologic barriers, introduction of chemical and biological immunosuppression, and prophylaxis for microbial infections. The potential for further improvement comes in 5 major areas: blood biomarkers for monitoring of rejection, drug-free transplantation through the development of stable tolerance, eliminating the impact of ischemia-reperfusion injury, xenotransplantation of porcine kidneys, and finally, the possibility of autologous regeneration of functioning kidney tissue to treat advanced kidney disease.
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Affiliation(s)
- Jeremy R Chapman
- Centre for Transplant and Renal Research, University of Sydney, Westmead Hospital, Westmead, NSW 2145, Australia.
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44
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O'Connell PJ, Zhang W, Menon MC, Yi Z, Schröppel B, Gallon L, Luan Y, Rosales IA, Ge Y, Losic B, Xi C, Woytovich C, Keung KL, Wei C, Greene I, Overbey J, Bagiella E, Najafian N, Samaniego M, Djamali A, Alexander SI, Nankivell BJ, Chapman JR, Smith RN, Colvin R, Murphy B. Biopsy transcriptome expression profiling to identify kidney transplants at risk of chronic injury: a multicentre, prospective study. Lancet 2016; 388:983-93. [PMID: 27452608 PMCID: PMC5014570 DOI: 10.1016/s0140-6736(16)30826-1] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Chronic injury in kidney transplants remains a major cause of allograft loss. The aim of this study was to identify a gene set capable of predicting renal allografts at risk of progressive injury due to fibrosis. METHODS This Genomics of Chronic Allograft Rejection (GoCAR) study is a prospective, multicentre study. We prospectively collected biopsies from renal allograft recipients (n=204) with stable renal function 3 months after transplantation. We used microarray analysis to investigate gene expression in 159 of these tissue samples. We aimed to identify genes that correlated with the Chronic Allograft Damage Index (CADI) score at 12 months, but not fibrosis at the time of the biopsy. We applied a penalised regression model in combination with permutation-based approach to derive an optimal gene set to predict allograft fibrosis. The GoCAR study is registered with ClinicalTrials.gov, number NCT00611702. FINDINGS We identified a set of 13 genes that was independently predictive for the development of fibrosis at 1 year (ie, CADI-12 ≥2). The gene set had high predictive capacity (area under the curve [AUC] 0·967), which was superior to that of baseline clinical variables (AUC 0·706) and clinical and pathological variables (AUC 0·806). Furthermore routine pathological variables were unable to identify which histologically normal allografts would progress to fibrosis (AUC 0·754), whereas the predictive gene set accurately discriminated between transplants at high and low risk of progression (AUC 0·916). The 13 genes also accurately predicted early allograft loss (AUC 0·842 at 2 years and 0·844 at 3 years). We validated the predictive value of this gene set in an independent cohort from the GoCAR study (n=45, AUC 0·866) and two independent, publically available expression datasets (n=282, AUC 0·831 and n=24, AUC 0·972). INTERPRETATION Our results suggest that this set of 13 genes could be used to identify kidney transplant recipients at risk of allograft loss before the development of irreversible damage, thus allowing therapy to be modified to prevent progression to fibrosis. FUNDING National Institutes of Health.
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Affiliation(s)
- Philip J O'Connell
- Renal Unit, University of Sydney at Westmead Hospital, Sydney, NSW, Australia
| | - Weijia Zhang
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Madhav C Menon
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Zhengzi Yi
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bernd Schröppel
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Lorenzo Gallon
- Department of Medicine-Nephrology and Surgery-Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Yi Luan
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ivy A Rosales
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Yongchao Ge
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bojan Losic
- Department of Genetics and Genomic Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Caixia Xi
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Christopher Woytovich
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Karen L Keung
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Chengguo Wei
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ilana Greene
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jessica Overbey
- Department of Health Evidence and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Emilia Bagiella
- Department of Health Evidence and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nader Najafian
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Milagros Samaniego
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Arjang Djamali
- Division of Nephrology, Department of Medicine, University of Wisconsin, Madison, WI, USA
| | - Stephen I Alexander
- Discipline of Child & Adolescent Health, The Children's Hospital at Westmead Clinical School, The University of Sydney, NSW, Australia
| | - Brian J Nankivell
- Renal Unit, University of Sydney at Westmead Hospital, Sydney, NSW, Australia
| | - Jeremy R Chapman
- Renal Unit, University of Sydney at Westmead Hospital, Sydney, NSW, Australia
| | - Rex Neal Smith
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert Colvin
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Barbara Murphy
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Krishnan AR, Wong G, Chapman JR, Coates PT, Russ GR, Pleass H, Russell C, He B, Lim WH. Prolonged Ischemic Time, Delayed Graft Function, and Graft and Patient Outcomes in Live Donor Kidney Transplant Recipients. Am J Transplant 2016; 16:2714-23. [PMID: 27037866 DOI: 10.1111/ajt.13817] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Revised: 02/22/2016] [Accepted: 03/24/2016] [Indexed: 01/25/2023]
Abstract
The association between prolonged cold ischemic time (CIT) and graft and patient outcomes in live donor kidney transplant recipients remains unclear. The aims of this study were to examine the association of CIT with delayed graft function and graft loss in live donor kidney transplant recipients and those who participated in the Australian Paired Kidney Exchange program using data from the Australia and New Zealand Dialysis and Transplant (ANZDATA) registry. Of 3717 live donor transplant recipients between 1997 and 2012 who were followed for a median of 6.6 years (25 977 person-years), 224 (25%) experienced CIT >4-8 h. Donor age was an effect modifier between CIT and graft outcomes. In recipients who received kidneys from older donors aged >50 years, every hour of increase in CIT was associated with adjusted odds of 1.28 (95% confidence interval [CI] 1.07-1.53, p = 0.007) for delayed graft function, whereas CIT >4-8 h was associated with adjusted hazards of 1.93 (95% CI 1.21-3.09, p = 0.006) and 1.91 (95% CI 1.05-3.49, p = 0.035) for overall and death-censored graft loss, respectively, compared with CIT of 1-2 h. Attempts to reduce CIT in live donor kidney transplants involving older donor kidneys may lead to improvement of graft outcomes.
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Affiliation(s)
- A R Krishnan
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Western Australia, Australia
| | - G Wong
- Australia and New Zealand Dialysis and Transplant Registry, South Australia, Australia.,Centre for Transplant and Renal Research, Westmead Hospital, New South Wales, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, New South Wales, Australia.,Sydney School of Public Health, University of Sydney, New South Wales, Australia
| | - J R Chapman
- Centre for Transplant and Renal Research, Westmead Hospital, New South Wales, Australia
| | - P T Coates
- Central and Northern Adelaide Renal and Transplantation Services, South Australia, Australia
| | - G R Russ
- Australia and New Zealand Dialysis and Transplant Registry, South Australia, Australia.,Central and Northern Adelaide Renal and Transplantation Services, South Australia, Australia
| | - H Pleass
- Centre for Transplant and Renal Research, Westmead Hospital, New South Wales, Australia
| | - C Russell
- Central and Northern Adelaide Renal and Transplantation Services, South Australia, Australia
| | - B He
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Western Australia, Australia
| | - W H Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Western Australia, Australia.,Australia and New Zealand Dialysis and Transplant Registry, South Australia, Australia
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46
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Chapman JR, Wong G. Cancer in patients with inherited ciliopathies: polycystic kidney disease. Lancet Oncol 2016; 17:1343-1345. [PMID: 27550647 DOI: 10.1016/s1470-2045(16)30307-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 07/04/2016] [Indexed: 12/25/2022]
Affiliation(s)
- Jeremy R Chapman
- Centre for Transplant and Renal Research, Westmead Hospital, Sydney, NSW 2145, Australia.
| | - Germaine Wong
- Centre for Transplant and Renal Research, Westmead Hospital, Sydney, NSW 2145, Australia
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47
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Lim WH, Chapman JR, Coates PT, Lewis JR, Russ GR, Watson N, Holdsworth R, Wong G. HLA-DQ Mismatches and Rejection in Kidney Transplant Recipients. Clin J Am Soc Nephrol 2016; 11:875-883. [PMID: 27034399 PMCID: PMC4858494 DOI: 10.2215/cjn.11641115] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 02/04/2016] [Indexed: 01/12/2023]
Abstract
BACKGROUND AND OBJECTIVES The current allocation algorithm for deceased donor kidney transplantation takes into consideration HLA mismatches at the ABDR loci but not HLA mismatches at other loci, including HLA-DQ. However, the independent effects of incompatibilities for the closely linked HLA-DQ antigens in the context of HLA-DR antigen matched and mismatched allografts are uncertain. We aimed to determine the effect of HLA-DQ mismatches on renal allograft outcomes. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Using data from the Australia and New Zealand Dialysis and Transplant Registry, we examined the association between HLA-DQ mismatches and acute rejections in primary live and deceased donor kidney transplant recipients between 2004 and 2012 using adjusted Cox regression models. RESULTS Of the 788 recipients followed for a median of 2.8 years (resulting in 2891 person-years), 321 (40.7%) and 467 (59.3%) received zero and one or two HLA-DQ mismatched kidneys, respectively. Compared with recipients who have received zero HLA-DQ mismatched kidneys, those who have received one or two HLA-DQ mismatched kidneys experienced greater numbers of any rejection (50 of 321 versus 117 of 467; P<0.01), late rejections (occurring >6 months post-transplant; 8 of 321 versus 27 of 467; P=0.03), and antibody-mediated rejections (AMRs; 12 of 321 versus 38 of 467; P=0.01). Compared with recipients of zero HLA-DQ mismatched kidneys, the adjusted hazard ratios for any and late rejections in recipients who had received one or two HLA-DQ mismatched kidneys were 1.54 (95% confidence interval [95% CI], 1.08 to 2.19) and 2.85 (95% CI, 1.05 to 7.75), respectively. HLA-DR was an effect modifier between HLA-DQ mismatches and AMR (P value for interaction =0.02), such that the association between HLA-DQ mismatches and AMR was statistically significant in those who have received one or two HLA-DR mismatched kidneys, with adjusted hazard ratio of 2.50 (95% CI, 1.05 to 5.94). CONCLUSIONS HLA-DQ mismatches are associated with acute rejection, independent of HLA-ABDR mismatches and initial immunosuppression. Clinicians should be aware of the potential importance of HLA-DQ matching in the assessment of immunologic risk in kidney transplant recipients.
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Affiliation(s)
- Wai H. Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
- Australia and New Zealand Dialysis and Transplant Registry, Adelaide, South Australia, Australia
| | - Jeremy R. Chapman
- Centre for Transplant and Renal Research, Westmead Hospital, Sydney, New South Wales, Australia
| | - Patrick T. Coates
- Central and Northern Adelaide Renal and Transplantation Services, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Joshua R. Lewis
- Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Graeme R. Russ
- Australia and New Zealand Dialysis and Transplant Registry, Adelaide, South Australia, Australia
- Central and Northern Adelaide Renal and Transplantation Services, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Narelle Watson
- New South Wales Transplantation and Immunogenetic Services, Australian Red Cross Service, Sydney, New South Wales, Australia; and
| | - Rhonda Holdsworth
- Transplantation Services, Australian Red Cross Services, Melbourne, Victoria, Australia
| | - Germaine Wong
- Australia and New Zealand Dialysis and Transplant Registry, Adelaide, South Australia, Australia
- Centre for Transplant and Renal Research, Westmead Hospital, Sydney, New South Wales, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
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48
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Chapman JR, Delmonico FL. Buyer beware transplantation. Kidney Int 2016; 89:983-985. [PMID: 27083275 DOI: 10.1016/j.kint.2016.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 01/28/2016] [Indexed: 10/21/2022]
Abstract
Poor long-term outcomes of commercial transplantation of transplant tourists reinforce the need to prevent this form of human trafficking. The development of an International Convention by the Council of Europe is highlighted and the implications for physicians of the criminalizing of organ trafficking are considered. The causes of poor outcomes from transplant tourism are considered, with the actions needed to provide both equity and sufficiency of access to transplantation as critical deterrent measures.
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Affiliation(s)
- Jeremy R Chapman
- Department of Medicine and Cancer, Westmead Hospital, Sydney, New South Wales, Australia.
| | - Francis L Delmonico
- Department of Surgery, Harvard Medical School at the Massachusetts General Hospital, Boston, Massachusetts, USA
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49
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Pinter J, Hanson CS, Craig JC, Chapman JR, Budde K, Halleck F, Tong A. 'I feel stronger and younger all the time'-perspectives of elderly kidney transplant recipients: thematic synthesis of qualitative research. Nephrol Dial Transplant 2016; 31:1531-40. [PMID: 27333617 DOI: 10.1093/ndt/gfv463] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Accepted: 12/29/2015] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Kidney transplantation offers improved survival and quality of life to an increasing number of elderly patients with end-stage kidney disease. However, elderly kidney transplant recipients may face unique challenges due to a higher burden of comorbidity, greater cumulative risk of immunosuppression-related complications and increasing frailty. We aimed to describe the perspectives of elderly kidney transplant recipients. METHODS Electronic databases were searched to April 2015. Qualitative studies were eligible if they reported views from elderly kidney transplant recipients (≥60 years). Thematic synthesis was used to analyse the findings. RESULTS Twenty-one studies involving >116 recipients were included. We identified seven themes. 'Regaining strength and vitality' meant valuing the physical and psychosocial improvements in daily functioning and life participation. 'Extending life' was the willingness to accept any organ, including extended criteria kidneys, to prolong survival. 'Debt of gratitude' entailed conscious appreciation toward their donor while knowing they were unable to repay their sacrifice. 'Moral responsibility to maintain health' motivated adherence to medication and lifestyle recommendations out of an ethical duty to protect their gift for graft survival. 'Unabating and worsening forgetfulness' hindered self-management. 'Disillusionment with side effects and complications' reflected disappointment and exasperation with the unintended consequences of medications. 'Finality of treatment option' was an acute awareness that the current transplant may be their last. CONCLUSIONS Kidney transplantation was perceived to slow and even reverse the experience of aging among elderly recipients, especially compared with dialysis. However, some were frustrated over persistent limitations after transplant, struggled with the burden of medication side effects and worried about a possible return to dialysis if the transplant failed. Clarifying patient expectations of transplantation, providing support to alleviate the debilitating impacts of immunosuppression and addressing fears about deteriorating health and graft failure may improve satisfaction and outcomes in elderly kidney transplant recipients.
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Affiliation(s)
- Jule Pinter
- Sydney School of Public Health, University of Sydney, Sydney, NSW 2006, Australia Centre for Kidney Research, Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Camilla S Hanson
- Sydney School of Public Health, University of Sydney, Sydney, NSW 2006, Australia Centre for Kidney Research, Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Jonathan C Craig
- Sydney School of Public Health, University of Sydney, Sydney, NSW 2006, Australia Centre for Kidney Research, Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Jeremy R Chapman
- Centre for Transplant and Renal Research, Westmead Hospital, Westmead, NSW, Australia
| | - Klemens Budde
- Department of Nephrology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Fabian Halleck
- Department of Nephrology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Allison Tong
- Sydney School of Public Health, University of Sydney, Sydney, NSW 2006, Australia Centre for Kidney Research, Children's Hospital at Westmead, Westmead, NSW, Australia
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50
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Ma MKM, Lim WH, Craig JC, Russ GR, Chapman JR, Wong G. Mortality among Younger and Older Recipients of Kidney Transplants from Expanded Criteria Donors Compared with Standard Criteria Donors. Clin J Am Soc Nephrol 2015; 11:128-36. [PMID: 26681136 DOI: 10.2215/cjn.03760415] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2015] [Accepted: 09/24/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVES The quality and age of donor organs are known to have a major effect on patient and graft outcomes, but it is uncertain whether this association is uniform for all recipients. We aimed to determine whether the use of expanded criteria deceased donor (ECD) kidneys for transplantation compared with standard criteria deceased donor (SCD) kidneys has a different association with survival in younger (age <60 years old) compared with older (age ≥60 years old) recipients. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Using data from the Australian and New Zealand Dialysis and Transplant Registry (1997-2009), we compared the risk of all-cause mortality and death with functioning graft among younger and older recipients who had received either an SCD or an ECD kidney using the adjusted Cox proportional hazard models. RESULTS In total, 3822 patients were transplanted between 1997 and 2009. Over a follow-up period of 21,249 person-years (a median duration of 5.3 years [interquartile range, 2.22-8.6 years]), 567 recipients (n=385 for those age <60 years old; n=182 for those age ≥60 years old) died. Recipient age was an effect modifier between donor types, all-cause mortality, and death with functioning graft (P values for interaction were 0.05 and 0.04, respectively). In younger recipients, there was an excess risk of all-cause mortality (adjusted hazard ratio [HR], 1.55; 95% confidence interval [95% CI], 1.23 to 1.97) and death with functioning graft (adjusted HR, 1.72; 95% CI, 1.28 to 2.29) after transplantation with ECD kidneys compared with SCD kidneys, but there was no statistically significant association among older recipients (adjusted HR, 1.11; 95% CI, 0.80 to 1.54 and adjusted HR, 1.30; 95% CI, 0.89 to 1.89, respectively). This excess risk was largely caused by death from cardiovascular disease. CONCLUSIONS There was an excess risk of all-cause mortality and death with functioning graft when younger recipients were transplanted with ECD kidneys compared with SCD kidneys. These findings suggest that caution is needed in allocating ECD kidneys to younger recipients.
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Affiliation(s)
- Maggie K M Ma
- Department of Medicine, Queen Mary Hospital, Hong Kong; Centre for Transplant and Renal Research, Westmead Hospital, New South Wales, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, New South Wales, Australia
| | - Wai H Lim
- Australian and New Zealand Dialysis and Transplant Registry, Adelaide, Australia; Department of Renal Medicine University of Western Sydney, New South Wales, Australia
| | - Jonathan C Craig
- Centre for Kidney Research, The Children's Hospital at Westmead, New South Wales, Australia; Sydney School of Public Health, University of Sydney, New South Wales, Australia; and
| | - Graeme R Russ
- Australian and New Zealand Dialysis and Transplant Registry, Adelaide, Australia; Central and Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, Australia
| | - Jeremy R Chapman
- Centre for Transplant and Renal Research, Westmead Hospital, New South Wales, Australia; Sydney School of Public Health, University of Sydney, New South Wales, Australia; and
| | - Germaine Wong
- Centre for Transplant and Renal Research, Westmead Hospital, New South Wales, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, New South Wales, Australia; Australian and New Zealand Dialysis and Transplant Registry, Adelaide, Australia; Sydney School of Public Health, University of Sydney, New South Wales, Australia; and
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