End-stage Kidney Disease Care Research Articles

Nephrologists' perspectives and experiences with hospice among older adults with end-stage kidney disease.

Hospice care leads to improved patient and family outcomes. Hospice use among older adults with end-stage kidney disease (ESKD) is markedly lower than among older adults with other serious illnesses, and the majority of those with ESKD who use hospice enroll in the last days of life. Here, our aim was to explore barriers to timely receipt of high-quality hospice care for older adults with ESKD. Utilizing a qualitative study design, we conducted a secondary analysis focused on hospice, a theme that we identified in our larger overarching study that involved semi-structured interviews with 20 nephrologists in the United States focused on treatment decision-making in older adults with advanced chronic kidney disease. We analyzed the interview transcripts using emergent thematic analysis to develop an understanding of barriers to high-quality hospice. With a couple notable exceptions, nephrologists voiced general support for the concept of hospice, but few recalled patients of theirs who had received hospice. Nephrologists' interviews revealed two interrelated contributors to the lack of timely access to high-quality hospice care for seriously ill older adults with ESKD: (1) nephrologists view dialysis and hospice as mutually exclusive models of care; (2) nephrologists feel unsure who should manage hospice care for patients with ESKD. The first contributor was rooted in nephrologists' narrow vision of when to consider hospice (informed, in part, by policy barriers) and, in a couple of cases, strong discomfort with hospice. The second stemmed from nephrologists' belief that neither they nor hospice are adequately prepared to provide hospice care for ESKD. Our findings suggest that, in addition to Medicare policy change, nephrologists need to receive more training in primary palliative care skills including in indications for hospice, initiating conversations about hospice with patients, and collaborating with hospice clinicians to care for these vulnerable patients.

Development of PD in lower-income countries: a rational solution for the management of AKI and ESKD

It is estimated that more than 50% of patients with end stage kidney disease (ESKD) in low-resource countries are unable to access dialysis. When hemodialysis is available, it often has high out of pocket expenditure and is seldom delivered to the standard recommended by international guidelines. Haemodialysis is a high cost intervention with significant negative effects on environmental sustainability, especially in resource poor countries (the ones most likely to be impacted by resultant climate change). This review discusses the rationale for peritoneal dialysis (PD) as a more resource and environmentally efficient treatment with the potential to improve dialysis access, especially to vulnerable populations, including women and children, in lower resource countries. Successful initiatives, such as the Saving Young Lives program, have demonstrated the benefit of PD for acute kidney injury. This can then serve as a foundation for later development of PD services for ESKD programs in these countries. Expansion of PD programs in resource poor countries has proven to be challenging for a variety of reasons. Hopefully, if some of these issues can addressed, PD will be able to permit an expansion of ESKD care in these countries.

Patient participation in end-stage kidney disease care: variation over time and effects of staff-directed interventions - a quasi-experimental study

BackgroundAmong those elements establishing decent quality of care from a patient perspective, opportunities to participate in accord with one’s individual needs and preferences are central. To date, little is known the extent of preference-based patient participation in kidney care, and what facilitates optimal conditions. This study investigated i) preference-based patient participation in kidney care over time, and ii) the effects of interventions designed to enhance person-centred patient participation.MethodsA quasi-experimental study was conducted across nine kidney care sites in southeast Sweden. A cohort of 358 patients with stage IV chronic kidney disease (eGRF 15–19 ml/min) or V (eGRF < 15 mL/min) entered the study. Of these, 245 patients (with kidney replacement therapy or intermittent outpatient visits only) completed a survey on patient participation at four time points: every six months from August 2019 to May 2021, patients reported their preferences for and experiences of participation using the validated Patient Preferences for Patient Participation tool, the 4Ps. Between the first and second data collection points, interventions were provided for designated staff to facilitate person-centred participation, using two strategies for two subgroups at three sites each: the managers receiving a bundle of information via e-mail on patient participation in a standard dissemination procedure (three sites), or an additional half-year support program for implementation offered to 1–2 staff per site (three sites), with no intervention for a control group (three sites). The differences in 4Ps data between groups were analysed using multilevel ordinal regression.ResultsOver time and across all sites, most patients’ experiences of participation fully or almost fully matched their engagement preferences (57%–90%). Still, up to 12% of patient reports indicated that their preferences and experiences were insufficiently matched: in these cases, the patients had preferred to be more involved than they had experienced, for example, in making healthcare plans and setting health-related goals. The interventions did not affect the levels of preference-based participation, but patients in the control group sites had slightly more consistent matches.ConclusionsLiving with kidney failure necessitates patient engagement, but opportunities to participate in accordance with one’s preferences are not fully provided for all patients. Additional efforts to support a common understanding and to ensure person-centred patient participation is still needed.

Causes of Hospitalization among End-Stage Kidney Disease Cohort before and after Hemodialysis.

Patients with end-stage kidney disease (ESKD) have a greater risk of comorbidities, including diabetes and anemia, and have higher hospital admission rates than patients with other diseases. The cause of hospital admissions is associated with ESKD prognosis. This retrospective cohort study involved patients with ESKD who received hemodialysis and investigated whether the cause of hospital admission changed before versus after they started hemodialysis. This study recruited 592 patients with ESKD who received hemodialysis at any period between January 2005 and November 2017 and had been assigned the International Classification of Diseases Ninth Revision Clinical Modification (ICD-9-CM) code for ESKD. The patients’ demographic data and hospitalization status one year before and two years after they received hemodialysis were analyzed. A McNemar test was conducted to analyze the diagnostic changes from before to after hemodialysis in patients with ESKD. The study’s sample of patients with ESKD comprised more women (51.86%) than men and had an average age of 67.15 years. The numbers of patients admitted to the hospital for the following conditions all decreased significantly after they received hemodialysis: type 2 (non-insulin-dependent and adult-onset) diabetes; native atherosclerosis; urinary tract infection; gastric ulcer without mention of hemorrhage, perforation, or obstruction; pneumonia; reflux esophagitis; duodenal ulcer without mention of hemorrhage, perforation, or obstruction; and bacteremia. Most patients exhibited one or more of the following comorbidities: diabetes (n = 407, 68.75%), hypertension (n = 491, 82.94%), congestive heart failure (n = 161, 27.20%), ischemic heart disease (n = 125, 21.11%), cerebrovascular accident (n = 93, 15.71%), and gout (n = 96, 16.22%). An analysis of variance (ANOVA) indicated that changes in the ICD-9-CM codes for native atherosclerosis, urinary tract infection, pneumonia, and hyperkalemia were associated with age. Patients who developed pneumonia before or after they received hemodialysis tended to be older (range: 69–70 years old). This study investigated the causes of hospital admission among patients with ESKD one year before and two years after they received hemodialysis. This study’s results revealed hypertension to be the most common comorbidity. Regarding the cause of admission, pneumonia was more prevalent in older than in younger patients. Moreover, changes in the ICD-9-CM codes of native atherosclerosis, urinary tract infection, pneumonia, and hyperkalemia were significantly correlated with age. Therefore, when administering comprehensive nursing care and treatment for ESKD, clinicians should not only focus on comorbidities but also consider factors (e.g., age) that can affect patient prognosis.

Accessibility and quality of haemodialysis services in an urban setting in South India: a qualitative multiperspective study

ObjectiveTo explore the accessibility and quality of existing haemodialysis services in an urban setting.SettingThe study was conducted in Bangalore city, India.ParticipantsA total of 28 stakeholders including 2 nephrologists, 7 duty...

Market Consolidation and Innovation in US Dialysis

While patients with end-stage kidney disease have benefited from innovations in clinical therapeutics and care delivery, these changes have been primarily incremental and have not fundamentally transformed care delivery. Dialysis markets are highly concentrated, which may impede innovation. Unique features of the dialysis industry that have contributed to consolidation can help to explain links between consolidation and innovation. We discuss these unique features and then provide a framework for considering the effects of consolidation on innovation in dialysis that focuses on the following economic considerations: (1) industry characteristics, composition, and stage of consolidation, (2) innovation characteristics and relative profitability, (3) the role of government regulation, and (4) innovation from smaller providers and new entrants. We present examples of how these considerations have influenced the adoption of alternative dialysis technologies such as peritoneal dialysis and erythropoietin-stimulating agents, and we discuss how consolidated markets can both help and hinder recent policy initiatives to transform dialysis care delivery. Only by considering these important drivers of consolidation, future efforts can be successful in transforming end-stage kidney disease care.

Healthcare utilization and expenditure among individuals with end-stage kidney disease in Taiwan

The prevalence of end-stage kidney disease (ESKD) in Taiwan has been increasing in recent decades. ESKD care and medical expenditures constitute an important part of the entire healthcare system. This study analyzed data collected from the National Health Insurance (NHI) Research Database from 2010 to 2018. The annual medical cost increased by approximately 4% both in the entire Taiwanese population and in its ESKD population. The total medical expenditure in the ESKD population from 2010 to 2018 increased from 48.03 to 65.65 billion reimbursement points, with dialysis treatments costing higher than non-dialysis treatments. ESKD outpatient and inpatient costs accounted for 10.4%-11.1% and 4.8%-5.6% of the entire NHI expenditure, respectively. The leading cause of inpatient costs was circulatory diseases, accounting for 29.3% of the total ESKD inpatient costs in 2018. Furthermore, percutaneous coronary intervention had the highest cost followed by simple percutaneous transluminal angioplasty. In 2018, the hemodialysis population had the highest average monthly cost of 73 thousand points per person, while the kidney transplant population had the lowest average monthly cost of 39 thousand points per person. Medical expenditure, including both inpatient and outpatient costs, of the ESKD population continued to grow from 2010 to 2018. The non-dialysis cost in the ESKD population was mainly for cardiovascular disease management and vascular access care, for which prevention will always be challenging.

Mapping the empirical evidence on patient involvement interventions in patients with end-stage kidney disease making end-of-life care decisions: a scoping review protocol.

The objective of this scoping review is to investigate and map existing empirical evidence on patient involvement interventions helping patients with end-stage kidney disease to make end-of-life care decisions about kidney services. Patients with end-stage kidney disease have a high disease burden and mortality rate. Despite this, kidney services differ in how they offer and integrate end-of-life care, if it is offered at all. Some countries have established advance care planning protocols to encourage patient involvement when offering end-of-life care options as part of end-stage kidney disease care. However, there is a limited understanding of the components of patient involvement interventions designed to support patients with end-stage kidney disease making decisions about end-of-life care. The review will consider studies on patient involvement interventions concerning end-of-life care decisions for patients with end-stage kidney disease. A broad definition of patient involvement interventions will be used. Studies on interventions that do not involve patients or relatives will be excluded. The review will focus on interventions applied to kidney health care and other services, such as community-based health care. MEDLINE, Embase, Scopus, and CINAHL will be searched. The literature will be screened for inclusion by two independent reviewers. Data synthesis will be conducted through relational analysis investigating patient involvement interventions and relevant information in line with the review objective and questions. Data will be extracted and listed in the data extraction instruments, accompanied by a narrative summary describing how the results relate to the review objective.

Environmental Impact of Care for End-stage Kidney Disease on the Earth and Humans.

Environmental Impact of Care for End-stage Kidney Disease on the Earth and Humans.

Current status of health systems financing and oversight for end-stage kidney disease care: a cross-sectional global survey

ObjectivesThe Global Kidney Health Atlas (GKHA) is a multinational, cross-sectional survey designed to assess the current capacity for kidney care across all world regions. The 2017 GKHA involved 125 countries...

Peritoneal Dialysis Utilization Globally and Opportunities in Lower Income Countries

There has been an expansion of peritoneal dialysis (PD) utilization globally over the past several years. This has occurred for several reasons. First, there has been a global increase in the number of patients receiving end-stage kidney disease (ESKD) treatment in high income, middle income and low income countries. Second, recent studies have emphasized the reduced cost of PD compared to hemodialysis (HD) if PD supplies can be acquired at a reasonable cost. Thirdly, it is now widely accepted that since PD is much simpler to do than HD (that is, it does not require large amounts of water, complex water treatment systems, electricity, and machinery), the use of PD in low resource countries has certain obvious advantages. Fourthly, it has become clear from experiences in Hong Kong and Thailand that have developed PD First programs (i.e. the government paying for ESKD care only if PD eligible patients start on PD rather than HD) and programs in Mexico (where there has been limited availability of HD centers) that the vast majority of patients with ESKD, even in low resource countries, are able to successfully be cared for with PD. And, importantly, as programs expand in low resource countries and experience is gained, outcomes of PD improve. Lastly, the International Society of Peritoneal Dialysis (ISPD) has developed comprehensive guidelines for the care of PD patients that has resulted in a dramatic improvement in outcomes for PD patients over the last several years.

Epidemiology of end-stage kidney disease

End-stage kidney disease (ESKD) is a common and morbid disease that affects patients’ quality and length of life, representing a large portion of health care expenditure in the United States. These patients commonly have associated diabetes and cardiovascular disease, with high rates of cardiovascular-related death. Management of ESKD requires renal replacement therapy via dialysis or transplantation. While transplantation provides the greatest improvement in survival and quality of life, the vast majority of patients are treated initially with hemodialysis. However, outcomes differ significantly among patient populations. Barriers in access to care have particularly affected at-risk populations, such as Black and Hispanic patients. These patients receive less pre-ESKD nephrology care, are less likely to initiate dialysis with a fistula, and wait longer for transplants—even in pediatric populations. Priorities for ESKD care moving into the future include increasing access to nephrology care in underprivileged populations, providing patient-centered care based on each patient’s “life plan,” and focusing on team-based approaches to ESKD care. This review explores ESKD from the perspective of epidemiology, costs, vascular access, patient-reported outcomes, racial disparities, and the impact of the COVID-19 crisis.

Perspectives and experiences of patients and healthcare professionals with geriatric assessment in chronic kidney disease: a qualitative study

BackgroundOlder patients with end-stage kidney disease (ESKD) often live with unidentified frailty and multimorbidity. Despite guideline recommendations, geriatric assessment is not part of standard clinical care, resulting in a missed opportunity to enhance (clinical) outcomes including quality of life in these patients. To develop routine geriatric assessment programs for patients approaching ESKD, it is crucial to understand patients’ and professionals’ experiences with and perspectives about the benefits, facilitators and barriers for geriatric assessment.MethodsIn this qualitative study, semi-structured focus group discussions were conducted with ESKD patients, caregivers and professionals. Participants were purposively sampled from three Dutch hospital-based study- and routine care initiatives involving geriatric assessment for (pre-)ESKD care. Transcripts were analysed inductively using thematic analysis.ResultsIn six focus-groups, participants (n = 47) demonstrated four major themes: (1) Perceived characteristics of the older (pre)ESKD patient group. Patients and professionals recognized increased vulnerability and (cognitive) comorbidity, which is often unrelated to calendar age. Both believed that often patients are in need of additional support in various geriatric domains. (2) Experiences with geriatric assessment. Patients regarded the content and the time spent on the geriatric assessment predominantly positive. Professionals emphasized that assessment creates awareness among the whole treatment team for cognitive and social problems, shifting the focus from mainly somatic to multidimensional problems. Outcomes of geriatric assessment were observed to enhance a dialogue on suitability of treatment options, (re)adjust treatment and provide/seek additional (social) support. (3) Barriers and facilitators for implementation of geriatric assessment in routine care. Discussed barriers included lack of communication about goals and interpretation of geriatric assessment, burden for patients, illiteracy, and organizational aspects. Major facilitators are good multidisciplinary cooperation, involvement of geriatrics and multidisciplinary team meetings. (4) Desired characteristics of a suitable geriatric assessment concerned the scope and use of tests and timing of assessment.ConclusionsPatients and professionals were positive about using geriatric assessment in routine nephrology care. Implementation seems achievable, once barriers are overcome and facilitators are endorsed. Geriatric assessment in routine care appears promising to improve (clinical) outcomes in patients approaching ESKD.

Barriers to Accessing Kidney Transplantation Among Populations Marginalized by Race and Ethnicity in Canada: A Scoping Review Part 1—Indigenous Communities in Canada

Background:Kidney transplantation (KT), a treatment option for end-stage kidney disease (ESKD), is associated with longer survival and improved quality of life compared with dialysis. Inequities in access to KT, and specifically, living donor kidney transplantation (LDKT), have been documented in Canada along various demographic dimensions. In this article, we review existing evidence about inequitable access and barriers to KT and LDKT for patients from Indigenous communities in Canada.Objective:To characterize the current state of literature on access to KT and LDKT among Indigenous communities in Canada and to answer the research question, “what factors may influence inequitable access to KT among Indigenous communities in Canada.”Eligibility criteria:Databases and gray literature were searched in June and November 2020 for full-text original research articles or gray literature resources addressing KT access or barriers in Indigenous communities in Canada. A total of 26 articles were analyzed thematically.Sources of evidence:Gray literature and CINAHL, OVID Medline, OVID Embase, and Cochrane databases.Charting methods:Literature characteristics were recorded and findings which described rates of and factors that influence access to KT were summarized in a narrative account. Key themes were subsequently identified and synthesized thematically in the review.Results:Indigenous communities in Canada experience various barriers in accessing culturally safe medical information and care, resulting in inequitable access to KT. Barriers include insufficient incorporation of Indigenous ways of knowing and being in information dissemination and care for ESKD and KT, spiritual concerns, health beliefs, logistical hurdles to accessing care, and systemic mistrust resulting from colonialism and systemic racism.Limitations:This review included studies that used various methodologies and did not assess study quality. Data on Indigenous status were not reported or defined in a standardized manner. Indigenous communities are not homogeneous and views on organ donation and KT vary by individual.Conclusions:Our scoping review has identified potential barriers that Indigenous communities may face in accessing KT and LDKT. Further research is urgently needed to better understand barriers and support needs and to develop strategies to improve equitable access to KT and LDKT for Indigenous populations in Canada.

Financial Evaluation of Kidney Transplant With Hepatitis C Viremic Donors to Uninfected Recipients.

Background.Kidney transplantation with hepatitis C viremic (dHCV+) donors appears safe for recipients without HCV when accompanied by direct acting antiviral (DAA) treatment. However, US programs have been reluctant to embrace this approach due to concern about insurance coverage. While the cost of DAA treatment is currently offset by the reduction in waiting time, increased competition for dHCV+ organs may reduce this advantage. This analysis sought to demonstrate the financial benefit of dHCV+ transplant for third-party health insurers to expand coverage availability.Methods.An economic analysis was developed using a Markov model for 2 decisions: first, to accept a dHCV+ organ versus wait for a dHCV uninfected organ; or second, accept a high kidney donor profile index (KDPI) (>85) organ versus wait for a better quality dHCV+ organ. The analysis used Medicare payments, historical survival data, cost report data, and an estimated cost of DAA of $29 874.Results.In the first analysis, using dHCV+ kidneys reduced the cost of end-stage kidney disease care if the wait for a dHCV uninfected organ exceeded 11.5 months. The financial breakeven point differed according to the cost of DAA treatment. In the second analysis, declining a high-KDPI organ in favor of a waiting dHCV+ organ was marginally clinically beneficial if waiting times were <12 months but not cost effective.Conclusions.dHCV+ transplant appears to be economically and clinically advantageous compared with waiting for dHCV-uninfected transplant but should not replace high-KDPI transplant when appropriate. Despite the high cost of DAA therapy, health insurers benefit financially from dHCV+ transplant within 1 year.

Defining the roles and responsibilities of the kidney transplant medical director: A necessary step for future training, mentoring, and professional development.

The management of a kidney transplant program has evolved significantly in the last decades to become a highly specialized, multidisciplinary standard of care for end-stage kidney disease. Transplant center job descriptions have similarly morphed with increasing responsibilities to address a more complex patient mix, increasing medical and surgical therapeutic options, and increasing regulatory burden in the face of an ever-increasing organ shortage. Within this evolution, the role of the Kidney Transplant Medical Director (KTMD) has expanded beyond the basic requirements described in the United Network for Organ Sharing bylaws. Without a clear job description, transplant nephrology trainees may be inadequately trained and practicing transplant nephrologists may face opaque expectations for the roles and responsibilities of Medical Director. To address this gap and clarify the key areas in which the KTMD interfaces with the kidney transplant program, American Society of Transplantation (AST) formed a Task Force of 14 AST KTMDs to review and define the role of the KTMD in key aspects of administrative, regulatory, budgetary, and educational oversight of a kidney transplant program.

Association of Chronic Condition Special Needs Plan With Hospitalization and Mortality Among Patients With End-Stage Kidney Disease

While several studies have demonstrated the benefit of enrollment in chronic condition special needs plans (C-SNPs) for other chronic diseases (eg, diabetes), there is no evaluation of the association of C-SNPs with outcomes among patients with end-stage kidney disease (ESKD). To examine whether and to what degree C-SNP enrollment was associated with improved clinical outcomes and quality of life in patients with ESKD. This multicenter cohort study included 2718 patients who were newly enrolled in an ESKD C-SNP between January 1, 2013, and September 30, 2017, and receiving dialysis from DaVita Kidney Care. Patients were followed up until death, loss to follow-up, or end of study (ie, December 31, 2018). Enrollees in C-SNP were matched via multiple clinical and demographic characteristics with 2 different control populations, as follows: (1) those in the same facilities (n = 2545) or (2) those in similar counties (n = 1986). Patients enrolled in CareMore C-SNPs (n = 206) were excluded from the study. Data analysis was conducted June to December 2019. Standard ESKD care with dialysis plus access to an integrated care team who worked with the patient and the dialysis team, comprehensive health assessments done by the integrated care team, and access to select benefits (such as vision and dental care) as a C-SNP enrollee. Hospitalizations, mortality, laboratory values indicative of metabolic control, and Kidney Disease Quality of Life 36-item (KDQOL-36) survey scores. The 2545 C-SNP enrollees in the facility-matched analysis had a mean (SD) age of 57.2 (12.9) years, and included 968 (38.0%) women, 1328 (52.2%) Hispanic individuals, and 553 (21.7%) African American individuals. The 1986 C-SNP enrollees in the county-matched analysis had a mean (SD) age of 57.8 (12.2) years, with 705 (35.5%) women, 1085 (54.6%) Hispanic individuals, and 472 (23.8%) African American individuals. Compared with patients not enrolled in C-SNP, enrollees had lower hospitalization rates, with incidence rate ratios of 0.90 (95% CI, 0.84-0.97; P = .006) in the facility-matched analysis and 0.76 (95% CI, 0.70-0.83; P < .001) in the county-matched analysis. Compared with patients not enrolled in C-SNP, enrollees had decreased mortality risk in the same facilities (hazard ratio, 0.77; 95% CI, 0.68-0.88; P < .001) and in the same counties (hazard ratio, 0.77; 95% CI, 0.66-0.88; P < .001). No significant differences were observed between C-SNP enrollees and matched patients in metabolic laboratory values or KDQOL-36 survey scores. This cohort study found a positive association of C-SNP enrollment with lower rates of hospitalization and mortality. The findings suggest that the additional services and benefits C-SNPs provide may improve outcomes compared with standard of care for patients with ESKD.

Fragmentation of care as a barrier to optimal ESKD management.

Caring for patients with end-stage kidney disease (ESKD) in the United States is challenging, due in part to the complex epidemiology of the disease's progression as well as the ways in which care is delivered. As CKD progresses toward ESKD, the number of comorbidities increases and care involves multiple healthcare providers from multiple subspecialties. This occurs in the context of a fragmented US healthcare delivery system that is traditionally siloed by provider specialty, organization, as well as systems of payment and administration. This article describes the role of care fragmentation in the delivery of optimal ESKD care and identifies research gaps in the evidence across the continuum of care. We then consider the impact of care fragmentation on ESKD care from the patient and health system perspectives and explore opportunities for system-level interventions aimed at improving care for patients with ESKD.

Barriers to optimal vascular access for hemodialysis.

Vascular access is the Achilles heel for hemodialysis (HD). An arteriovenous fistula (AVF), considered the optimal access for HD, rather than a graft or central venous catheter (CVC) caused the "Fistula First" initiative to dominate quality assessment. However, this initiative had the unintended consequence of increasing the proportion of less desirable catheters, leading to "Fistula First, Catheter Last". But as the end-stage kidney disease (ESKD) population expanded with aging, sicker patients, individual assessment of the appropriate access changed the paradigm to KDOQI's "Patient First: ESKD Life-Plan" to attain the "right access, in the right patient, at the right time, for the right reasons". However, such a goal has proved elusive because the optimal vascular access does not currently exist. Thus, ESKD care providers attempting to offer the "right access" must weigh the barriers to achieving the most optimal access to suit each of their HD patients. The barriers are based on shortcomings related specifically to each of the three vascular accesses and to characteristics of each ESKD patient's demographics, physical factors, quality of life, and cost considerations. This article will describe these barriers so that clinicians caring for ESKD patients initiating or receiving HD provide the most optimal vascular access for that specific patient.

TUBULO-INTERSTITIAL NEPHRITIS IN GRAFT KIDNEY TRANSPLANT POST AZATHIOPRINE INTRODUCTION

Kidney Transplant is the gold standard of care for end-stage kidney disease (ESKD). Immunosuppression has a central role to maintain the graft function and its survival. Despite newer agents, still, old agents such as azathioprine are still used by many clinicians at various places worldwide. However, hypersensitivity reactions, such as tubulointerstitial nephritis, can occur after starting these medications. There can be many causes of tubulointerstitial nephritis; drugs, infections and autoimmune diseases e.g.: sarcoidosis, systemic lupus erythematosus and Sjogren’s syndrome. We report a case of acute interstitial nephritis after the introduction of azathioprine in a kidney transplant recipient. A young female with a living related kidney transplant on triple immunosuppression medication consisting of prednisolone, tacrolimus and mycophenolate mofetil, expressed her desire to conceive eight months after her wedding. Accordingly, mycophenolate mofetil was replaced by azathioprine. In subsequent visits, it was observed that her graft kidney function was deteriorating progressively. All possible causes which could contribute to graft function deterioration were evaluated and a graft biopsy was performed. The biopsy showed moderate interstitial inflammatory infiltrate rich in eosinophils with no evidence of cellular or antibody-mediated rejection.It was successfully treated by stopping azathioprine and starting high dose oral prednisolone.Deterioration of kidney function in kidney transplant patients, who are put on azathioprine, should raise the suspicion of tubulointerstitial nephritis as a differential diagnosis. To the best of our knowledge, this is the first report of a kidney transplant recipient in whom graft kidney function deteriorated upon introduction of azathioprine. Kidney biopsy revealed moderate interstitial inflammatory infiltrate rich in eosinophils with no evidence of cellular or antibody-mediated rejection. The graft kidney function improved after the cessation of azathioprine and increasing the dose of steroids.