Care Of Kidney Transplant Recipients Research Articles

Optimal care for kidney transplant recipients

Optimal care for kidney transplant recipients

KHA‐CARI guideline: KHA‐CARI adaptation of the KDIGO Clinical Practice Guideline for the Care of Kidney Transplant Recipients

The latest Caring for Australians with Renal Impairment (CARI) guideline detailing renal transplant care, developed as a local modification of the Kidney Disease Improving Global Outcomes (KDIGO) guidelines.

Immunosuppression: Does One Regimen Fit All?

There has been considerable interest in the individualization of immunosuppressive regimens in an attempt to avoid side effects and improve long-term outcomes. Most available studies have addressed steroid and calcineurin inhibitor minimization in an attempt to prevent the development of chronic allograft dysfunction and cardiovascular mortality. Herein, we evaluate the available evidence for incorporation of these novel strategies in standard clinical care of kidney transplant recipients. Protocol biopsies, pharmacogenetics, and other assays have been developed to guide tailoring of immunosuppression; however, although promising results have been obtained, trials showing their ability to improve long-term outcome are lacking and urgently needed.

Endorsement of the Kidney Disease Improving Global Outcomes (KDIGO) guidelines on kidney transplantation: a European Renal Best Practice (ERBP) position statement

KDIGO (Kidney Disease: Improving Global Outcomes) is an international independent body aiming to 'improve the care and outcomes of kidney disease patients worldwide, through the development and implementation of clinical practice guidelines'. Recently, the KDIGO work group has produced comprehensive clinical practice guidelines for the care of kidney transplant recipients (KTRs). The guideline makes recommendations for immunosuppression, graft monitoring, as well as prevention and treatment of infection, cardiovascular disease, malignancy and other complications that are common in KTRs, including haematological and bone disorders. Because most guidelines were 'soft' rather than 'strong', and because global guidelines need to be adapted and implemented into the regional context where they are used, the European Renal Best Practice (ERBP) Advisory Board appointed a work group of transplant nephrologists and surgeons to review the newest KDIGO guideline and comment on its relevance and applicability for European KTRs. In this article, we concentrate only on those guidelines which we considered worth amending or adapting. All guidelines not mentioned are fully endorsed.

Skin Cancer Prevention Education for Kidney Transplant Recipients: A Systematic Evaluation of Internet Sites

Repeated patient education about skin cancer prevention is important to self-care after transplant. Examine educational materials for kidney transplant recipients available on the Internet that address sun protection and skin self-examination for early detection of squamous cell carcinoma. Systematic review of Web sites for kidney transplant recipients endorsed by transplant physicians and dermatologists. An expert panel of 8 dermatologists providing care for kidney transplant recipients and 1 research medical anthropologist. Reading grade level, inclusion of people with skin of color, sufficient content to support effective sun protection, and description of 4 sun-protection strategies and skin self-examination. Results-Of the 40 sites identified, 11 contained information about sun protection or increased risk of any type of cancer. The Web sites had a ninth-grade median reading level (range, seventh grade to college senior). Interrater reliability for the 25-item assessment tool was assessed by Fleiss' kappa (kappa = 0.87). Skin cancer risk was presented as relevant to those with fair skin. Sites recommended regular use of sunscreen with sun-protection factor of 15 or greater (n=3) to reduce the risk of skin cancer (n=4). Few sites recommended using protective clothing (n=5), seeking shade (n=4), and avoiding deliberate tanning with indoor or outdoor light (n=1). Five sites recommended skin self-examination. Because many patients seek self-management information from the Internet, Web sites must provide more thorough educational information about skin cancer prevention and health promotion at a lower reading grade level.

Skin cancer prevention education for kidney transplant recipients: a systematic evaluation of Internet sites

Repeated patient education about skin cancer prevention is important to self-care after transplant. Examine educational materials for kidney transplant recipients available on the Internet that address sun protection and skin self-examination for early detection of squamous cell carcinoma. Systematic review of Web sites for kidney transplant recipients endorsed by transplant physicians and dermatologists. An expert panel of 8 dermatologists providing care for kidney transplant recipients and 1 research medical anthropologist. Reading grade level, inclusion of people with skin of color, sufficient content to support effective sun protection, and description of 4 sun-protection strategies and skin self-examination. Results-Of the 40 sites identified, 11 contained information about sun protection or increased risk of any type of cancer. The Web sites had a ninth-grade median reading level (range, seventh grade to college senior). Interrater reliability for the 25-item assessment tool was assessed by Fleiss' kappa (kappa = 0.87). Skin cancer risk was presented as relevant to those with fair skin. Sites recommended regular use of sunscreen with sun-protection factor of 15 or greater (n=3) to reduce the risk of skin cancer (n=4). Few sites recommended using protective clothing (n=5), seeking shade (n=4), and avoiding deliberate tanning with indoor or outdoor light (n=1). Five sites recommended skin self-examination. Because many patients seek self-management information from the Internet, Web sites must provide more thorough educational information about skin cancer prevention and health promotion at a lower reading grade level.

KDIGO-Leitlinien - Betreuung von Nierentransplantatempfängern

KDIGO-Leitlinien umfassen eine Vielzahl von Fragen der Langzeitnachsorge nach einer Nierentransplantation. Die einzelnen Empfehlungen geben wertvolle Hinweise, sind allerdings weit davon entfernt, alle Eventualitäten nach einer Nierentransplantation zu regeln. Leitlinien, die „weltweit“ gelten, machen dies auch nahezu unmöglich. Der wesentliche Gesichtspunkt dieser Leitlinie ist, dass mit einem Minimalprogramm eine Nierentransplantation peri- und postoperativ sowie in der Langzeitnachsorge sicher organisiert und durchgeführt werden kann. Die Leitlinie soll auch ermutigen, ein Nierentransplantationsprogramm weiter auszubauen und Patienten dieser Form der Nierenersatztherapie zuzuführen.

Individualizing Early Use of Sirolimus in Renal Transplantation

One of the main goals in the current care of kidney transplant recipients is to extend long-term graft survival. Efficacious immunosuppressive agents devoid of nephrotoxicity are needed. In human clinical transplantation, sirolimus combined with other immunosuppressive drugs has proven to be a powerful immunosuppressant capable of preventing acute graft rejection, as well as of improving renal function, renal histology, and graft survival when compared with immunosuppressive regimens that include calcineurin inhibitors. The valuable experience gained through many clinical studies allows clinicians to plan sirolimus use. We present a review of the clinical experience and literature review on the use of sirolimus in the first 12 months posttransplantation.

Canadian Society of Transplantation and Canadian Society of Nephrology Commentary on the 2009 KDIGO Clinical Practice Guideline for the Care of Kidney Transplant Recipients

KDIGO (Kidney Disease: Improving Global Outcomes) is an international initiative to develop and implement clinical practice guidelines. In November 2009, KDIGO published its guideline for the management of kidney transplant recipients.1 This guideline was extremely comprehensive and spanned more than 150 pages. The Canadian Society of Transplantation (CST) and the Canadian Society of Nephrology (CSN) congratulate KDIGO, members of the guideline work group, and the evidence review team for producing such a thorough and exhaustive document.

KDOQI US Commentary on the 2009 KDIGO Clinical Practice Guideline for the Care of Kidney Transplant Recipients

In response to recently published KDIGO (Kidney Disease: Improving Global Outcomes) guidelines for the care of kidney transplant recipients (KTRs), the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) organized a working group of transplant nephrologists and surgeons to review these guidelines and comment on their relevance and applicability for US KTRs. The following commentaries on the KDIGO guidelines represent the consensus of our work group. The KDIGO transplant guidelines concentrated on aspects of transplant care most important to this population in the posttransplant period, such as immunosuppression, infection, malignancy, and cardiovascular care. Our KDOQI work group concurred with many of the KDIGO recommendations except in some important areas related to immunosuppression, in which decisions in the United States are largely made by transplant centers and are dependent in part on the specific patient population served. Most, but not all, KDIGO guidelines are relevant to US patients. However, implementation of many may remain a major challenge because of issues of limitation in resources needed to assist in the tasks of educating, counseling, and implementing and maintaining lifestyle changes. Although very few of the guidelines are based on evidence that is strong enough to justify their being used as the basis of policy or performance measures, they offer an excellent road map to navigate the complex care of KTRs.

The KDIGO review of the care of renal transplant recipient

This review highlights the key messages from the KDIGO (Kidney Disease: Improving Global Outcomes) clinical practice guidelines for care of kidney transplant recipients, which were written to be global guidelines irrespective of the regulatory, fiscal, cultural, socioeconomic, or geographical environment. The distillation of 3168 randomized control trials, 7543 cohort studies, and 1609 reviews led to recommendations rated by the strength of supporting evidence and the quality of the data from A to D. Despite this, the quality of the evidence is surprisingly low for the majority of decisions that are routinely taken in all transplant units throughout the world, highlighting the needs for properly designed randomized controlled trials. The principle areas covered in the guidelines include immunosuppression, management of acute rejection, monitoring of the patient and graft, chronic allograft injury, kidney biopsy, nonadherence, vaccination, infectious diseases, cardiovascular risk management, malignancy, bone disease, pediatric growth, lifestyle, fertility, and mental health. This review highlights a number of these areas for consideration focusing on the different types of evidence that we use in daily clinical practice.

The KDIGO Clinical Practice Guidelines for the Care of Kidney Transplant Recipients

The clinical guideline for care of renal transplant recipients was written by a committee of 15 people from nine countries, supported by an evidence review team The scope of the review was care of the patient after a renal transplant-not evaluation or selection of recipients and donors, focusing on the issue specific to the immunosuppressed transplant patient. A total of 12,327 articles comprising 3168 randomized controlled trials, 7543 cohort studies, and 1609 reviews were selected by a formal search. Each article was formally evaluated for the quality of the data from A to D. A consistent set of statements were based on the strength of the evidence. Level 1 evidence: "we recommend" means that if you were a patient, most people would want to do this; if a clinician, you should recommend this course of action to most patients; and if a policy maker, you should adopt this as a reasonable standard. Level 2 evidence: "we suggest" means the majority of patients would want do this; to the clinician, it means that different solutions may well be needed for different patients; whereas to the health policy maker, this is a strong warning to engage stakeholders in the creation of a particular local policy. Because 69% of the advice is "suggested" on the basis of level C or D evidence, one outcome of this work is to make it clear where the current evidence for clinical decisions runs out of data.

KDIGO guideline for the care of kidney transplant recipients will be resource challenged

The Executive Summary of the KDIGO Clinical Practice Guideline for the Care of Kidney Transplant Recipients is presented in this issue of Kidney International. This guideline will require careful attention for implementation in the context of available resources within each country, especially those with underdeveloped economies.

Measuring vs estimating glomerular filtration rate in kidney transplantation

Evaluation of kidney function is crucial in the care of kidney transplant recipients and in the design and interpretation of clinical trials in transplantation. Kidney function is most commonly assessed in both instances using serum creatinine concentration or an estimate of glomerular filtration rate (GFR) based on serum creatinine. These are inexpensive, widely available, and easily administered. Both have significant drawbacks, notably with respect to their inability to accurately identify changes in GFR. Novel markers of GFR such as cystatin C and beta-trace protein show promise as accurate and sensitive markers of GFR but have not yet been adequately evaluated in kidney transplantation. In addition, they are relatively expensive compared to creatinine and their assays are not available in most clinical laboratories. Glomerular filtration rate measurement using a variety of different available tracers and techniques is infrequently used in either clinical care or research protocols because of its cost and cumbersomeness. This review will discuss the merits and pitfalls of the various tools available to evaluate GFR in kidney transplantation.

The D&T Report

The D&T Report

Kidney Disease: Improving Global Outcomes

Kidney Disease: Improving Global Outcomes (KDIGO) is an independent organization with the mission to improve care and outcomes of patients with kidney disease worldwide through the development and coordination of clinical practice guidelines. KDIGO has established firm links with other organizations that have previously produced clinical practice guidelines in the field of kidney disease. The first three KDIGO guidelines--treatment of hepatitis C, management of bone and mineral disease, and care of kidney transplant recipients--have been finalized and the next three--acute kidney injury, management of glomerulonephritis, and management of blood pressure in chronic kidney disease--are under development. The ultimate goal is to cover most major aspects of care for patients with kidney disease. Corner stones of KDIGO's guideline development process are independent, multidisciplinary, international work groups, close collaboration with professional methodology experts who perform systematic evidence reviews, and open public review of each guideline. Grades of Recommendation Assessment, Development, and Evaluation (GRADE) methodology is applied for grading the quality of evidence and strength of recommendations. International conferences organized by KDIGO support the coordination of guideline development, assess the suitability of guideline topics and help to establish global consensus on definitions and policies.

A Report of the Lisbon Conference on the Care of the Kidney Transplant Recipient

An International Conference on the Care of the Kidney Transplant Recipient was convened in Lisbon, Portugal from February 2– 4, 2006 under the auspices of the National Kidney Foundation and Kidney Disease: Improving Global Outcomes (KDIGO), and in cooperation with The Transplantation Society. Conference participants included over 100 experts and leaders in kidney transplantation, representing more than 40 countries from around the world, including participants from Africa, Asia, Australia, Europe, North American, and South America (Appendix). The goal of the conference was to develop recommendations to improve the outcomes of kidney transplant recipients worldwide with regard to the following basic medical issues: cardiovascular disease (Work Group I), cancer and infection (Work Group II), and anemia, bone disease, reproductive issues, growth and development (Work Group III). Work Groups I, II, and III addressed the preand posttransplant care of kidney transplant recipients by the following components: timelines of preand posttransplantation, immunosuppression, level of kidney allograft function, and burden of disease (prior history of dialysis or preemptive transplant and how that history affects outcome). A graft maintenance section (Work Group IV) addressed: 1) recipient (and donor) selection; 2) surgical aspects and immediate posttransplant care of recipients including consideration of minimal surgical infrastructure; 3) immunosuppression including an assessment of the incremental expected value of more complex and expensive regimens in comparison to simpler and less expensive regimens, generics, midand long-term immunosuppression; 4) living donor versus deceased donor transplantation; and 5) midand long-term posttransplant care and monitoring of allograft function. In addition, conference participants were asked to examine the issue of applicability of the recently published Kidney Disease Outcomes Quality Initiative (KDOQI) clinical practice guidelines for chronic kidney disease (CKD) in kidney allograft recipients (1). Specifically, Work Group V addressed the role of estimated glomerular filtration rate (eGFR) in monitoring kidney function after transplantation, as well as the stratification for intervention according to eGFR values.

Smoothing Things over: The Transition from Pediatric to Adult Care for Kidney Transplant Recipients

Transition is a planned movement of adolescents with chronic physical and medical conditions from child-centered to adult-oriented healthcare systems as opposed to a purely administrative event. To evaluate the transition of pediatric kidney transplant recipients to the adult service at Guy's Hospital between 2000 and 2001 as compared with best practice from the literature, and to establish client satisfaction with the process. Data were collected by means of a retrospective review of case notes, clinician interview, and a patient satisfaction questionnaire, and analyzed by a single reviewer. Sixteen cases were analyzed with respect to their progress over the period of 1 year before and 1 year after transfer by looking at markers of adherence; a clinician's subjective assessment of overall graft stability before, during, and after transfer; and whether subjects chose to attend the transitional clinic. There was no qualitative difference in adherence or control among the patients who experienced the transitional clinic and those who did not. Patients who were considered stable and adherent before transition were not necessarily the same following transfer and vice versa. Patients who experienced the transitional clinic were not more satisfied as a group, although 9 of 11 thought their transition was "OK" or better. This is an extremely challenging area of pediatric nephrology; all patients need a high level of support. Services cannot be targeted to high-risk groups.

Smoothing things over: the transition from pediatric to adult care for kidney transplant recipients

Smoothing things over: the transition from pediatric to adult care for kidney transplant recipients

Medical Care of Kidney Transplant Recipients after the First Posttransplant Year

Kidney transplantation is the treatment of choice for patients with ESRD. Despite improvements in short-term patient and graft outcomes, there has been no major improvement in long-term outcomes. The use of kidney allografts from expanded-criteria donors, polyoma virus nephropathy, underimmunosuppression, and incomplete functional recovery after rejection episodes may play a role in the lack of improvement in long-term outcomes. Other factors, including cardiovascular disease, infections, and malignancies, also shorten patient survival and therefore reduce the functional life of an allograft. There is a need for interventions that improve long-term outcomes in kidney transplant recipients. These patients are a unique subset of patients with chronic kidney disease. Therefore, interventions need to address disease progression, comorbid conditions, and patient mortality through a multifaceted approach. The Kidney Disease Outcomes Quality Initiative from the National Kidney Foundation, the European Best Practice Guidelines, and the forthcoming Kidney Disease: Improving Global Outcomes clinical practice guidelines can serve as a cornerstone of this approach. The unique aspects of chronic kidney disease in the transplant recipient require the integration of specific transplant-oriented problems into this care schema and a concrete partnership among transplant centers, community nephrologists, and primary care physicians. This article reviews the contemporary aspects of care for these patients.