Functioning Kidney Transplant Research Articles

#364 Patient characteristics, treatment history and prognosis of adult survivors of childhood kidney replacement therapy—an ERA Registry study

Abstract Background and Aims Young adults who initiated kidney replacement therapy (KRT) during childhood and reached their 18th birthday (i.e. adult survivors of childhood KRT) are a particularly challenging patient group. Besides the changes associated with adolescence, they go through a transition from paediatric to adult nephrology centres, in which patients are expected to take responsibility of their own care. This increases the risk of non-compliance to treatment and graft failure. Nevertheless, not many epidemiological studies have focused on adult survivors of childhood KRT. This type of study would support healthcare providers in obtaining knowledge about the prognosis of this patient group and, perhaps, recognizing possibilities of treatment improvements. We aimed to provide up-to-date information on patient characteristics, treatment history, (graft) survival, 5-year prognosis and expected remaining lifetime of adult survivors of childhood KRT. Method KRT data was used from 21 European countries/regions that contributed with individual patient data to the European Renal Association (ERA) Registry. Adult survivors of childhood KRT, reaching the age of 18 years between 2008 and 2019, were included in the analysis, and their patient characteristics and treatment trajectories were examined. Kaplan-Meier and Cox proportional hazards regression were used in patient and graft survival analyses. The expected remaining lifetime of all KRT patients from the age of 18 years onwards was calculated overall and stratified by sex and treatment modality at the 18th birthday. Results We included 2 944 patients in the analysis, most of them were 10-14 (32.9%) or 15-17 (30.6%) years at start of KRT, and congenital anomalies of the kidney and urinary tract (CAKUT) were the most frequent cause of kidney failure (38.8%). Peritoneal dialysis was the most common treatment at start of KRT (37.8%), yet the percentage of adult survivors who received a pre-emptive kidney transplant increased from 25.6% in 2008-2011 to 32.4% in 2016-2019. By their 18th birthday, 81.4% of patients had a functioning kidney transplant. The overall unadjusted 5-year patient survival after their 18th birthday was 96.9% (95% CI 96.2-97.5), yet adult survivors on dialysis had an almost 4 times higher risk of death than their peers with a functioning kidney graft (adjusted HR 3.76 (95% CI: 2.55-5.53)). Besides, about 21% of the grafts failed during the 5 years after the 18th birthday (unadjusted 5-year graft survival: 78.9% (95% CI: 77.1-80.7)). Eighteen-year-old kidney transplant recipients reached 74% of the expected remaining lifetime of the general population, whereas dialysis patients only reached 37%. Conclusion Even at the young age of 18 years the remaining life expectancy of kidney transplant recipients was lower compared with the general population, and about one fifth of the grafts failed within 5 years after the patients’ 18th birthday. Still, as expected, adult survivors with a functioning kidney transplant at 18 years showed better outcomes than the ones on dialysis, with a greater 5-year survival and longer life expectancy. This epidemiological study reports on one of the biggest cohorts of adult survivors of childhood KRT studied to date. It provides unique knowledge on the prognosis of these patients, establishing the first step towards the optimization of care in this challenging patient group.

#1002 End of life healthcare utilisation and costs of older patients receiving kidney replacement therapy—analysis of Dutch health insurance claims data

Abstract Background and Aims The increasing prevalence of chronic kidney disease (CKD), an aging population and advancements in treatment options collectively contribute to a rise in older patients with a functioning kidney transplant (KTX) or undergoing dialysis. These treatments are associated with extensive healthcare utilisation, placing substantial demands on both patients and the healthcare system. Healthcare utilisation typically increases near the end of life, and is associated with increased costs. However, little is known about the end-of-life healthcare utilisation of patients receiving kidney replacement therapy (KRT). Therefore, our study aims to assess healthcare utilisation and costs during the last year of life. Method We analysed Dutch health insurance claims data from patients aged >65 years on KRT who deceased between June 2016 and December 2021. We matched each patient with two controls, defined as individuals who died within the same calendar year without any insurance claims related to CKD or KRT. Matching was performed on sex, age and socio-economic status. The primary outcomes were healthcare utilisation and costs in the last twelve months of life for patients treated with different KRT modalities and compared to matched controls. Healthcare utilisation was detailed at hospital and intensive care unit (ICU) admissions, emergency department (ED) and outpatient department (OPD) visits, hospital daycare and institutionalised care. Healthcare costs encompassed costs related to primary care, hospital care (inpatient and outpatient), mental care, institutionalised care, prescription medication, transportation and other costs. Hospital care costs were categorised as KRT-related and -unrelated costs. Results In total 7279 decedents were included; 4614 haemodialysis patients (HD), 766 peritoneal dialysis (PD) patients and 1899 KTx recipients. KRT patients had a mean age of 77.6 ± 6.6 years, with 64% being male, and had significantly more comorbidities than the control group. In the year preceding death, KRT patients had significantly more hospital admissions, ICU admissions, ED visits, outpatient visits, hospital daycare and institutionalised care than controls (see Fig. 1). When comparing across KRT-modalities, KTx patients were more often admitted to the ICU than HD and PD patients (p = 0.001 and p = 0.024, respectively). For both HD, PD and KTx patients, the mean number of days admitted to the hospital and ICU, as well as ED visits and OPD visits significantly increased in last three months preceding death, compared to the initial nine months of the last year of life (p < 0.0001). Mean total healthcare costs in the last year of life were €59.489 for KTx patients, €108.294 for PD and €117.520 for HD patients, compared to €19.820 for the controls. The majority of costs for dialysis patients were attributed to KRT, accounting for 55.5% (€65.216) and 60.0% (€64.559) of the total expenditures for HD and PD patients, respectively. In contrast, KRT-related costs constituted 25.7% (€15.262) of the total expenses in KTx patients. Besides substantial KRT-related costs, KRT-patients also incurred higher costs for specialist care in the hospital, primary care, medication and transport, compared to controls. Conclusion Healthcare utilisation is substantial for older KRT patients and intensifies during the last year of life. This is accompanied with elevated costs. Further research is necessary to evaluate the impact of healthcare utilisation on the quality of life and whether advanced care planning could prevent overutilisation.

#520 Trends in kidney replacement therapy in Central and Eastern Europe—data from the ERA Registry

Abstract Background and Aims Despite huge efforts to accomplish equitable access to high-quality healthcare, large disparities in kidney care delivery remain across Europe. Economic factors are considered to be the driving force behind differences in access to kidney replacement therapy (KRT), with lower access in lower-income countries. There is a sparsity of epidemiological data on KRT in Central and Eastern Europe. Therefore, we aimed to examine time trends in incidence and prevalence of KRT in Central and Eastern Europe from 2010 to 2021. Method We included incidence and prevalence data on patients starting or receiving KRT between the years 2010 and 2021 from 18 Central and Eastern European countries participating in the ERA Registry. Albania, Belarus, Bulgaria, Cyprus, Czech Republic, Latvia, Lithuania, Northern Macedonia, Poland, Russia, Slovakia, Turkey, and Ukraine provided data on aggregated level, whereas Bosnia and Herzegovina, Estonia, Greece, Romania and Serbia provided individual patient data. General population data were reported by the collaborating registries or extracted from Eurostat. Most registries had full coverage of the general population. We expressed incidence and prevalence per million population (pmp) and time trends were studied with Joinpoint regression and expressed as Annual Percentage Changes (APCs). Results Incidence of KRT varied largely across Central and Eastern European countries (Fig. 1). In 2010, it ranged from 23.0 pmp in Ukraine to 190.5 pmp in Greece, and in 2021 from 53.0 pmp in Ukraine to 283.0 pmp in Cyprus. In 7 countries the KRT incidence increased significantly between 2010 and 2021 (APC; 95% CI): Albania (+8%; 5-10%), Cyprus (+6%; 4-9%), Greece (+3%; 3-4%), North Macedonia (+4%; 3-5%), Romania (+3%; 1-5%), Russia (+9%; 7-10%), and Ukraine (+7%; 4-9%). Serbia was the only country in which KRT incidence decreased: from 188.6 pmp in 2010 to 65.9 pmp in 2021 (APC: −8%; −10 to −6%), whereas for other countries KRT incidence remained stable over the study period. Except for the Baltic States, the age of incident KRT patients increased in all countries during the study period, also reflected by a temporal increase in the proportion of patients initiating KRT at ages of 65 years and older. The KRT prevalence also showed large variation across countries, ranging from 123.6 pmp to 1080.0 pmp in 2010 in Ukraine and Greece (Fig. 1). In 2021 it ranged from 303.6 pmp (Ukraine) to 1445.4 pmp (Greece). In all, but five countries (Belarus, Bosnia and Herzegovina, Czech Republic, North Macedonia, and Serbia) the prevalence of KRT increased annually with 2-9% between 2010 and 2021. This increase was mainly driven by an increase in prevalent patients with a functioning kidney transplant. If, however, the period prior to the COVID-19 pandemic was considered (2010 to 2019) there was also an increasing trend in the KRT prevalence for Bosnia and Herzegovina, Czech Republic, and North Macedonia. In all countries, prevalent KRT patients became older during recent years. Conclusion Large variation exists in the number of incident and prevalent patients treated with KRT across Central and Eastern Europe. In the majority of countries the incidence of KRT remained stable between 2010 and 2021, whereas in about one third of countries the incidence of KRT significantly increased. On the other hand, in most countries the number of prevalent KRT patients significantly increased over the study period, especially prior to the COVID-19 pandemic. This increase was mainly driven by an increase in prevalent kidney transplant recipients. Patients on KRT tended to become older in the entire region, reflecting both the aging population, as well as the increasing willingness and capacity to treat elderly patients. Nevertheless, large country variations in the epidemiology of KRT remain and this study is a first important step to define country-specific priorities for the optimization of kidney care and to create further public awareness for kidney diseases in the Central and Eastern European region.

Blood pressure lowering for kidney transplant recipients: systematic review with network meta-analysis.

Hypertension affects 50-90% of kidney transplant recipients and is associated with cardiovascular disease and graft loss. We aimed to evaluate the comparative benefits and harms of blood pressure lowering agents in people with a functioning kidney transplant. We conducted a systematic review with network meta-analysis of randomized controlled trials (RCTs). We searched MEDLINE, Embase, and CENTRAL through to October 2023. RCTs evaluating blood pressure lowering agents administered for at least 2 weeks in people with a functioning kidney transplant with and without preexisting hypertension were eligible. Two reviewers independently extracted data. The primary outcome was graft loss. Treatment effects were estimated using random effects network meta-analysis, with treatment effects expressed as an odds ratio (OR) for binary outcomes and mean difference (MD) for continuous outcomes together with their 95% confidence interval (CI). Confidence in the evidence was assessed using GRADE for network meta-analysis. Ninety-four studies (7547 adults) were included. Two studies were conducted in children. No blood pressure-lowering agent reduced the risk of graft loss, withdrawal because of adverse events, death, cardiovascular or kidney outcomes compared with placebo/other drug class. Angiotensin-converting enzyme inhibitors and angiotensin receptor blocker therapy may incur greater odds of hyperkalemia compared with calcium channel blockers [odds ratio (OR) 5.48, 95% confidence interval (CI) 2.47-12.16; and OR 8.67, 95% CI 2.65-28.36; low certainty evidence, respectively). The evidentiary basis for the comparative benefits and safety of blood pressure lowering agents in people with a functioning kidney transplant is limited to guide treatment decision-making.

Short- and long-term outcomes of acute diverticulitis in patients with transplanted kidneys.

The safety of nonoperative treatment for patients with transplanted kidneys who develop acute diverticulitis is unclear. Our primary aim was to examine the long-term sequelae of nonoperative management in this group. We performed a population-based retrospective cohort study using linked administrative databases housed at ICES in Ontario, Canada. We included adult (≥18 years) patients admitted with acute diverticulitis between April 2002 and December 2019. Patients with a functioning kidney transplant were compared with those without a transplant. The primary outcome was failure of conservative management (operation, drainage procedure or death due to acute diverticulitis) beyond 30 days. The cumulative incidence function and a Fine-Grey subdistribution hazard model were used to evaluate this outcome accounting for competing risks. We examined 165 patients with transplanted kidneys and 74 095 without. Patients with transplanted kidneys were managed conservatively 81% of the time at the index event versus 86% in nontransplant patients. Short-term outcomes were comparable, but cumulative failure of conservative management at 5 years occurred in 5.6% (95% CI 2.3%-11.1%) of patients with transplanted kidneys versus 2.1% (95% CI 2.0%-2.3%) in those without. Readmission for acute diverticulitis was also higher in transplanted patients at 5 years at 16.7% (95% CI 10.1%-24.7%) versus 11.6% (95% CI 11.3%-11.9%). Adjusted analyses showed increased failure of conservative management [subdistribution hazard ratio (sHR) 3.24, 95% CI 1.69-6.22] and readmissions (sHR 1.55, 95% CI 1.02-2.36) for patients with transplanted kidneys. Most patients with transplanted kidneys are managed conservatively for acute diverticulitis. Although long-term readmission and failure of conservative management is higher for this group than the nontransplant population, serious outcomes are infrequent, substantiating the safety of this approach.

Using Photovoice to Explore the Lived Environment and Experience of Older Adults with Frailty on their Kidney Transplant Journey.

Older adults with frailty and kidney failure face higher waitlist mortality and are more likely to be listed as inactive on the kidney transplant (KT) wait list. Photovoice is a qualitative participatory research method where participants use photographs to represent their environment, needs and experiences. It offers unique insight into the lived environment and experience of patients and may offer direction in how to improve functional independence, symptom burden, and kidney transplant outcomes in adults with frailty. This photovoice study was embedded within a larger intervention adaptation project. Participants with pre-frailty or frailty awaiting a KT or recently post-transplant took photos with Polaroid cameras and wrote short descriptions for 11 prompts. Each participant completed a semi-structured interview wherein their photos were discussed. The team coded and discussed photos and interviews to determine overarching themes and implications. Focus groups were used to triangulate visual data findings. Sixteen participants completed both the photovoice and interview. Participants were a mean age of 60.5 years, 31.2% female, 43.4% self-identifying as Black, and 69% were frail. Outcomes were categorized into seven themes: functional space, home safety, medication management, adaptive coping, life changing nature of dialysis, support and communication. Visual data clarified and sometimes changed the interpretations of the text alone. Especially within the themes of home safety and functional space, safety hazards not previously recognized in the literature, like dialysis fluid storage, were identified. Photovoice contextualizes the living conditions and experiences of adults with frailty on the kidney transplant journey and could be a useful tool in geriatric nephrology and transplant. Addressing issues of home storage, organization, and accessibility should be explored as potential intervention targets. Incorporating participant values and goals into care decisions and interventional design should be further explored.

Patient Perspectives of Center-Specific Reporting in Kidney Failure Care: An Australian Qualitative Study

IntroductionPublic reporting of quality of care indicators in healthcare is intended to inform consumer decision-making, however people may be unaware such information exists or it may not capture their priorities. The aim of this study was to understand the views of people with kidney disease about public reporting of dialysis and transplant centre outcomes. MethodsThis qualitative study involved twenty-seven patients with lived experience of kidney disease in Australia who participated across eleven online focus groups between August and December 2022. Transcripts were analysed thematically. ResultsPatients from all Australian states and territories participated, with 22 (81%) having a functioning kidney transplant and 22 (81%) having current or previous experience of dialysis. Five themes were identified: 1) Surrendering to the health system, 2) The complexity of quality, 3) Benefits for patient care and experience, 4) Concerned about risks and unintended consequences, 5) Optimising the impact of data. ConclusionPatients desire choice among kidney services but perceive this as rarely possible in the Australian context. Health professionals are trusted to make decisions about appropriate centres. Public reporting of centre outcomes may induce fear and a loss of balanced perspective, but was supported by all participants and represents an opportunity for self-advocacy and informed decision-making. Strategies to mitigate potential risks include availability of trusted clinicians and community members to aid in data interpretation, providing context about centres and patients, and framing statistics to promote positivity and hope.

Postoperative Outcomes After Gastrointestinal Surgery in Patients Receiving Chronic Kidney Replacement Therapy: A Population-based Cohort Study.

This study evaluated the postoperative mortality and morbidity outcomes following the different subtypes of gastrointestinal (GI) surgery over a 15-year period. Patients receiving chronic kidney replacement therapy (KRT) experience higher rates of general surgery compared with other surgery types. Contemporary data on the types of surgeries and their outcomes are lacking. KRT was defined as patients requiring chronic dialysis (hemodialysis or peritoneal dilaysis) or having a functioning kidney transplant long-term. All incident and prevalent patients aged greater than 18 years identified in the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry as receiving chronic KRT were linked with jurisdictional hospital admission datasets between January 1, 2000 until December 31, 2015. Patients were categorized by their KRT modality [hemodialysis (HD), peritoneal dialysis (PD), home hemodialysis (HHD), and kidney transplant (KT)]. GI surgeries were categorized as upper gastrointestinal (UGI), bowel (small and large bowel), anorectal, hernia surgery, cholecystectomy, and appendicectomy. The primary outcome was the rates of the different surgeries, estimated using Poisson models. Secondary outcomes were risks of 30-day/in-hospital postoperative mortality risk and nonfatal outcomes and were estimated using logistic regression. Independent predictors of 30-day mortality were examined using comorbidity-adjusted Cox models. Overall, 46,779 patients on chronic KRT were linked to jurisdictional hospital datasets, and 9,116 patients were identified as having undergone 14,540 GI surgeries with a combined follow-up of 76,593 years. Patients on PD had the highest rates of GI surgery (8 per 100 patient years), with hernia surgery being the most frequent. Patients on PD also had the highest risk of 30-day postoperative mortality following the different types of GI surgery, with the risk being more than 2-fold higher after emergency surgery compared with elective procedures. Infective postoperative complications were more common than cardiac complications. This study also observed a U-shaped association between body mass index (BMI) and mortality, with a nadir in the 30 to 35kg/m 2 group. Patients on chronic KRT have high rates of GI surgery and morbidity, particularly in those who receive PD, are older, or are either underweight or moderately obese.

Long COVID Among Kidney Transplant Recipients Appears to Be Attenuated During the Omicron Predominance.

Omicron variant has been associated with milder cases of COVID-19 among kidney transplant recipients. However, little is known about postacute sequelae, referred to as Long COVID. Prospective, single-center cohort study investigating prevalence and risk factors for Long COVID among kidney transplant recipients during the omicron predominance in Brazil. The analysis included adult patients with confirmed SARS-CoV-2 infection between January 5, 2022, and July 18, 2022, were alive, had a functioning kidney transplant 3 mo after symptom onset, and answered a telephonic survey about physical complains of Long COVID. From the 1529 eligible, 602 (39%) patients responded the survey. Sixteen percent reported a previous SARS-CoV-2 infection, and 85% had been fully vaccinated. The prevalence of Long COVID was 52%, with the most common complaints being weakness (46%), myalgia (41%), dizziness (33%), and headache (31%). Among employed patients, 94% were able to resume their normal work activities. In multivariable analysis, female gender (hazard ratio [HR], 2.14; 95% confidence interval [CI], 1.51-3.02; P < 0.0001), previous SARS-CoV-2 infection (HR, 3.55; 95% CI, 1.91-6.60; P < 0.0001), fatigue (HR, 2.32; 95% CI, 1.18-4.55; P = 0.014), myalgia (HR, 1.48; 95% CI, 1.03-2.15; P = 0.036) during the acute phase, and hospitalization because of COVID-19 (HR, 1.71; 95% CI, 1.06-2.76; P = 0.028) were independently associated with Long COVID. In the "omicron era," Long COVID among kidney transplant recipients exhibited milder characteristics and had a less significant impact on their ability to resume normal life activities. The risk factors for persistent symptoms were similar to those observed in the general population except for the vaccination status, underscoring the importance of closer monitoring in special subgroups.

The Effect of the SystemCHANGETM Intervention on Systems Thinking in a Randomized Controlled Trial of Adult Kidney Transplant Recipients: A Secondary Data Analysis

Objective: The SystemCHANGE™ intervention is an approach that harnesses patients′ recurring personal systems of established routines of daily living, environments, and important others as reliable ′personalized system solutions′ to support habitual medication-taking and improve medication adherence. In a secondary data analysis, we (1) analyzed the association between the longitudinal trajectories of systems thinking and medication adherence, and (2) examined the extent that demographic characteristics and the SystemCHANGE™ intervention influenced these trajectories. Methods: Participants were ≥ 18 years of age who had received a kidney???only transplant, self???administered at least one prescribed immunosuppressive medication twice daily, had a functioning kidney transplant, were not in the hospital, and had no diagnosis that would immediately shorten the lifespan. We conducted a single???blinded (participants), 2???arm randomized controlled trial (RCT). An intervention group received the 6-month SystemCHANGETM intervention, and the attention-control group received the 6-month education intervention. Systems thinking was measured using the Systems Thinking Scale (adapted for patients). Results: The parallel process growth curve model with time-invariant predictors suggested that participants with higher levels of systems thinking at baseline demonstrated greater gains in systems thinking over time (r=0.407). White participants exhibited greater baseline levels of systems thinking than African-American participants (d=0.76). Participants assigned to the SystemCHANGE™ group maintained their medication adherence rates over time, whereas control counterparts demonstrated significantly different, declining trajectories of medication adherence (d=−0.41). Conclusion: We found shared co-variance between systems thinking and medication adherence and the SystemCHANGE™ intervention. The SystemCHANGE™ intervention was efficacious in improving and sustaining medication adherence in adult kidney transplant recipients.

The Deceased Transplant Recipients: A Forgotten Source of Organ Donors

Background: Organ transplantation is the most successful therapy for end-stage organ disease since it increases the quality of life and life expectancy. For these reasons, over 107,000 patients were on the waitlist in the United States for a transplant in 2022. Unfortunately, only 42,887 transplants were performed, and annually, over 7000 patients on the kidney list die or are too sick to transplant. To solve this severe organ shortage, the use of the deceased transplant recipients with functioning organs, whether transplanted or native, is explored as a new source of organ donors. Methods: To assess the feasibility of this option, first, we will review the rate of kidney transplant recipients dying with functioning grafts (DWGF), their re-use, the organ allocation system, the technical aspects of the organ procurement, and the transplantation of the DWGF kidneys. Then, we will consider the larger group of all deceased transplant recipients as potential donors for all functioning, native, or transplanted organs. Conclusions: (1). All functioning kidney transplants explanted from the deceased transplant recipients have excellent long-term function after re-transplantation. (2). The other functioning organs constitute a large unrecognized pool of transplantable organs. (3). The intensivists and the transplant community should be educated about these new options to improve the organ shortage.

#3156 REAL WORLD CHARACTERISTICS, SYMPTOM BURDEN AND TREATMENT PATTERNS OF ANAEMIA OF CKD IN EGYPT, SAUDI ARABIA, SOUTH AFRICA, AND TURKEY

Abstract Background and aims Patients with chronic kidney disease (CKD) often have comorbid anaemia [1]. Real-world data on patient characteristics, disease burden, and treatment management for people with anaemia of CKD in the Middle East and Africa are limited. Methods SATISFY (Survey on treatment patterns in Anemia of CKD, patient Treatment satISFaction and perspectives as reported by patients with phYsicians) was a real-world survey conducted between 01 June to 01 September 2022 in Egypt, Saudi Arabia, South Africa, and Turkey. Physician and patient perceptions of treatment were captured via cross-sectional surveys; patients’ clinical characteristics were recorded by physicians in electronic case report forms via retrospective review of medical records. Eligible physicians were nephrologists with ≥1 years’ experience who managed ≥12 patients with anaemia of CKD per month and with drug management experience for anaemia of CKD. Physicians collected data on the first 7–10 patients seen in routine clinical practice during the study period. Eligible patients were ≥18 years with CKD stage 3b, 4, or 5 at the time of anaemia of CKD diagnosis and with ≥2 years’ follow-up data from diagnosis to time of survey. Patients with functioning kidney transplants or acute kidney injury were excluded. Primary outcomes were to describe clinical and demographic characteristics, monitoring test results, treatment patterns of patients with anaemia of CKD, physicians’ reasons for not treating anaemia of CKD, and physicians’ and patients’ reasons for therapy choice. Data were analysed descriptively. Results A total of 1788 patients and 217 physicians were included; 1138 patients (64%) were non-dialysis dependent (NDD) and 611 (34%) were dialysis dependent (DD) at the time of data extraction (n = 39 [2%] data missing). Mean (standard deviation [SD]) age was 46 (14) years, mean (SD) body mass index was 24.1 (3.1) kg/m2, 56% (n = 1004) were male, and median (interquartile range [IQR]) follow-up from diagnosis of anaemia of CKD was 2.6 (2.5–3.2) years. The most common comorbidities were hypertension (n = 858, 48%) and diabetes (n = 324, 18%). Symptom burden was high, with lack of energy and fatigue being among the most commonly reported symptoms by physicians and patients across both NDD and DD groups (Figure 1). Differences were seen between physician and patient symptom reporting and between NDD and DD groups. Patients’ self-reported symptom burden was greater than that reported by physicians, particularly for NDD patients. The median (IQR) times per year physicians reported testing CKD patients for anaemia was 4 (4–6) for NDD patients and 12 (10–12) for DD patients. Median test levels for haemoglobin at which patients were diagnosed were lower than those reported by physicians as being used for diagnosis; similar results were seen for thresholds used to initiate treatment (Table 1). Median (IQR) days from diagnosis to first treatment was 61 (0–419). Of those who received treatment, the most common first treatment option was erythropoietin-stimulating agents + intravenous iron for both patients with NDD and DD anaemia of CKD at diagnosis (NDD n = 291/736, 40%; DD n = 170/316, 54%). A large proportion of patients never received treatment for anaemia of CKD (n = 701, 39%). The most important reasons to not initiate treatment from a physician perspective were patient refusal (n = 172, 79%) and risk of adverse reactions (n = 168, 77%); for patients, top reasons were that their symptoms were not severe (n = 168, 22%) and their physicians’ concerns about adherence (n = 116, 15%). Similar reasons were seen for both the Middle East and Africa regions. Conclusion Symptom burden is high in patients with anaemia of CKD in the Middle East and Africa, particularly lack of energy and fatigue. Differences were seen between physician and patient perceptions of symptom burden and between NDD and DD groups. Substantial treatment inertia exists. Physicians rated patient refusal and risk of adverse reactions as main reasons for not treating patients, while patients attributed this to a belief that their symptoms were not severe.

Patient Safety with Fluid Removal with In-Center Hemodialysis.

Fluid management, which is discussed in the article “Ultrafiltration Rate Levels in Hemodialysis Patients Associated with Weight-Specific Mortality Risks,”1 published in this issue of CJASN, has been an aspect of dialysis care that I believe should be the top priority for doctors to manage and has been getting much more attention this past decade. Failure to establish and maintain an appropriate dry weight can lead to serious complications. I would add that if the patient crashes because of dialysis fluid removal and they believe that the treatment itself is causing them pain, it can lead them to miss or shorten treatment or even discontinue vital care. The authors concluded that “ultrafiltration rates associated with various levels of higher mortality risk depend on body weight, but not in a 1:1 ratio, and are different in men versus women, in high–body weight older patients, and in high-vintage patients.”1 As a youth, I had both my kidneys removed as the doctors believed this could help my high BP. After my double nephrectomy, my BP remained very high, and I was hospitalized frequently for it. I was switched to peritoneal dialysis, and within weeks, my BP normalized to 100/70, and I no longer required BP medication. I found myself having to increase my fluid and sodium intake to help maintain my BP. Thankfully, because of either a working kidney transplant or effective fluid management on dialysis, I have not had high BP in decades. Ultrafiltration and fluid removal is a delicate balance, and the goal of hourly fluid ultrafiltration removal is dependent on changes in the intravascular volume. Using volume monitoring, I witnessed my body reacting differently every time I had a hemodialysis treatment, despite the fact that my ultrafiltration goal for my dry weight guestimate was consistent. I could see the difference in my tolerance level if I consumed more sodium in between treatments. It is not surprising to me that weight is a factor in ultrafiltration efficacy. People who maintain higher body weight most likely have a better appetite and may consume more salt, leading them to consume more fluids. Albumin levels would be good to study in comparison and to see if people who have normalized albumin levels tolerate ultrafiltration better. If diabetes is not properly managed, the patient's thirst affects fluid removal goals. In addition, the arbitrary dry weight number the physician sets as a guestimate for dialysis ultrafiltration could change because of hospitalization, changes in eating habits, or other health events. The use of ultrafiltration profiling, in which a predetermined rate of fluid is programmed to be removed per hour, lacks a timely feedback function showing how the patient is tolerating the volume shifts. The feedback is only apparent when the patient has symptoms either of fluid overload or crashing. The kidney community lacks education about crashing on dialysis. When you crash, it does not mean you are at a correct dry weight. The opposite is also true: If you do not have any crashing and have a smooth treatment, this does not mean you are at a correct dry weight. I have heard numerous stories of my peers losing 10–20 pounds of fluid with a functioning kidney transplant within days of surgery. I have experienced great anxiety when my ultrafiltration rate was increased, and I know my peers do as well. Again, the opposite is true: If we think it is too low, we worry about how it will limit our ability to drink fluid in between treatments. It is well documented that people on peritoneal dialysis keep their existing kidney function longer. Preserving existing kidney function plays a big role in our overall health. I was able to keep my existing kidney transplant function for a year during hemodialysis because of the fact that blood volume depletion was monitored and minimized to not dry out my kidney. Ultrafiltration rates can have serious consequences in our overall health. You cannot take too little, and you cannot take too much—you have to take the right amount. Fluid removal is a dynamic process. A sex-, weight-, and vintage patient–indexed ultrafiltration rate measure demonstrates the health disparities of patients on dialysis. However, without an understanding of albumin levels with blood volume changes, along with a patient's overall assessment, it is unclear how this measure will improve patient care or reduce mortality.

Symptomatic scrotal-inguino-retroperitoneal lymphocele in a kidney transplant patient—to drain but how to drain?

Scrotal-inguino-retroperitoneal (SIR) lymphocele is a rare complication following kidney transplant. This entity is characterized by a tract originating in the retroperitoneal space, through the inguinal canal and scrotum following lymph hydrodissection. Systematic review investigating SIR lymphocele yielded cases with open fenestration of the sac into the peritoneum as treatment. We described a case report of a male in his 60s with a functioning kidney transplant and SIR lymphocele, which was successfully managed in the short term with percutaneous drainage of the collection. However, the collection recurred and computed tomography scan showed a multiloculated collection that prompted surgical management. Intraoperatively, the encapsulated fluid-filled tract was excised and a drain was placed, which was removed 48h later. The patient wore a hernia belt for 6weeks as support. He had no recurrence of his lymphocele following serial reviews for 9months now.

Acute Thrombosis of the Inferior Vena Cava and Iliofemoral Veins in Patients with Functioning Kidney Transplants: Favorable Outcomes with Multi-modality Venous Recanalization and Change in Pre-Transplant Evaluation

Acute Thrombosis of the Inferior Vena Cava and Iliofemoral Veins in Patients with Functioning Kidney Transplants: Favorable Outcomes with Multi-modality Venous Recanalization and Change in Pre-Transplant Evaluation

The unmet need of organ transplantation in Africa.

The unmet need of organ transplantation in Africa.

СЕРИЯ КЛИНИЧЕСКИХ СЛУЧАЕВ ТЯЖЕЛОГО ТЕЧЕНИЯ ИНФЕКЦИИ COVID-19 У РЕЦИПИЕНТОВ ПОЧЕЧНЫХ ТРАНСПЛАНТАТОВ

Coronavirus infection has had a significant impact on people around the world, however, there is a category of patients who are at high risk of severe disease - kidney transplant recipients. The high risk is due to the presence of a pronounced comorbid background, long-term background immunosuppression, a high risk of secondary infection, and graft dysfunction as a result of a severe infection. This paper presents a series of clinical cases of severe COVID-19 infection in kidney transplant recipients. We have demonstrated that timely diagnosis and intensive therapy, including both adequate drug therapy and the use of renal replacement therapy in the form of hemodialysis and extracorporeal detoxification methods, can not only save the lives of such patients, but also preserve a functioning kidney transplant.

Hip Arthroplasty Outcomes in the Presence of Kidney Failure: A National Data Linkage Study

BackgroundPatients who have kidney failure are at higher risk of requiring total hip arthroplasty (THA) and are at higher risk of complications. This study compared the rate of revision surgery and mortality following THA between patients who have kidney failure receiving long term dialysis or who had a kidney transplant and those who did not have kidney failure. MethodsA data linkage study was performed using data from 2 national registries: a registry of dialysis and kidney transplant patients and a registry of THA procedures. Both registries had coverage of almost all procedures or treatments in Australia. Data from September 1999 to December 2016 were used. Mortality and revision surgery were compared between patients receiving dialysis, those who had a functioning kidney transplant, and patients who did not have kidney failure using Cox and Fine-Gray (competing risk) regression models. A total of 383,478 primary THA procedures were identified as people receiving dialysis (n = 490), who had a functioning kidney transplant (n = 459), or who did not have kidney failure (n = 382,529). ResultsThere was no significant difference in the overall rate of revision surgery between the groups (dialysis versus no kidney failure HR = 1.20; 95% CI 0.76, 1.88, transplant versus no kidney failure (hazard ratio) HR = 1.01; 95% (confidence interval) CI 0.66, 1.53). The risk for death after surgery was significantly higher in the dialysis group compared to both the functioning transplant group (HR = 3.44; 95%CI 1.58, 7.5), and in those without kidney failure (HR = 4.13; 95%CI 3.25, 5.25). ConclusionThe rate of mortality after THA in patients on dialysis is higher than in patients who have a functioning transplant or those who do not have kidney failure, but there is no early excess mortality to suggest a difference in this metric due to the surgery.

Projecting the future: modelling Australian dialysis prevalence 2021-30.

Objectives To project the prevalence of people receiving dialysis in Australia for 2021-30 to inform service planning and health policy. Methods Estimates were based on data from 2011 to 2020 from the Australia & New Zealand Dialysis & Transplant (ANZDATA) Registry and the Australian Bureau of Statistics. We projected dialysis and functioning kidney transplant recipient populations for the years 2021-30. Discrete-time, non-homogenous Markov models were built on probabilities for transition between three mutually exclusive states (Dialysis, Functioning Transplant, Death), for five age groups. Two scenarios were employed - stable transplant rate vs a continued increase - to assess the impact of these scenarios on the projected prevalences. Results Models projected a 22.5-30.4% growth in the dialysis population from 14 554 in 2020 to 17 829 ('transplant growth') - 18 973 ('transplant stable') by 2030. An additional 4983-6484 kidney transplant recipients were also projected by 2030. Dialysis incidence per population increased and dialysis prevalence growth exceeded population ageing in 40-59 and 60-69 year age groups. The greatest dialysis prevalence growth was seen among those aged ≥70 years. Conclusion Modelling of the future prevalence of dialysis use highlights the increasing demand on services expected overall and especially by people aged ≥70 years. Appropriate funding and healthcare planning must meet this demand.

Alternative strategies to increase the immunogenicity of COVID-19 vaccines in kidney transplant recipients not responding to two or three doses of an mRNA vaccine (RECOVAC): a randomised clinical trial

An urgent need exists to improve the suboptimal COVID-19 vaccine response in kidney transplant recipients (KTRs). We aimed to compare three alternative strategies with a control single dose mRNA-1273 vaccination: a double vaccine dose, heterologous vaccination, and temporary discontinuation of mycophenolate mofetil or mycophenolic acid. This open-label randomised trial, done in four university medical centres in the Netherlands, enrolled KTRs without seroconversion after two or three doses of an mRNA vaccine. Between Oct 20, 2021, and Feb 2, 2022, 230 KTRs were randomly assigned block-wise per centre by a web-based system in a 1:1:1 manner to receive 100 μg mRNA-1273, 2 × 100 μg mRNA-1273, or Ad26.COV2-S vaccination. In addition, 103 KTRs receiving 100 μg mRNA-1273, were randomly assigned 1:1 to continue (mycophenolate mofetil+) or discontinue (mycophenolate mofetil-) mycophenolate mofetil or mycophenolic acid treatment for 2 weeks. The primary outcome was the percentage of participants with a spike protein (S1)-specific IgG concentration of at least 10 binding antibody units per mL at 28 days after vaccination, assessed in all participants who had a baseline measurement and who completed day 28 after vaccination without SARS-CoV-2 infection. Safety was assessed as a secondary outcome in all vaccinated patients by incidence of solicited adverse events, acute rejection or other serious adverse events. This trial is registered with ClinicalTrials.gov, NCT05030974 and is closed. Between April 23, 2021, and July 2, 2021, of 12 158 invited Dutch KTRs, 3828 with a functioning kidney transplant participated in a national survey for antibody measurement after COVID-19 vaccination. Of these patients, 1311 did not seroconvert after their second vaccination and another 761 not even after a third. From these seronegative patients, 345 agreed to participate in our repeated vaccination study. Vaccination with 2 × mRNA-1273 or Ad26.COV2-S was not superior to single mRNA-1273, with seroresponse rates of 49 (68%) of 72 (95% CI 56-79), 46 (63%) of 73 (51-74), and 50 (68%) of 73 (57-79), respectively. The difference with single mRNA-1273 was -0·4% (-16 to 15; p=0·96) for 2 × mRNA-1273 and -6% (-21 to 10; p=0·49) for Ad26.COV2-S. Mycophenolate mofetil- was also not superior to mycophenolate mofetil+, with seroresponse rates of 37 (80%) of 46 (66-91) and 31 (67%) of 46 (52-80), and a difference of 13% (-5 to 31; p=0·15). Local adverse events were more frequent after a single and double dose of mRNA-1273 than after Ad26.COV2-S (65 [92%] of 71, 67 [92%] of 73, and 38 [50%] of 76, respectively; p<0·0001). No acute rejection occurred. There were no serious adverse events related to vaccination. Repeated vaccination increases SARS-CoV-2-specific antibodies in KTRs, without further enhancement by use of a higher dose, a heterologous vaccine, or 2 weeks discontinuation of mycophenolate mofetil or mycophenolic acid. To achieve a stronger response, possibly required to neutralise new virus variants, repeated booster vaccination is needed. The Netherlands Organization for Health Research and Development and the Dutch Kidney Foundation.