Improvement In Kidney Transplantation Research Articles

Normothermic ex vivo kidney perfusion for graft quality assessment prior to transplantation.

Normothermic ex vivo kidney perfusion (NEVKP) represents a novel approach for graft preservation and functional improvement in kidney transplantation. We investigated whether NEVKP also allows graft quality assessment before transplantation. Kidneys from 30-kg pigs were recovered in a model of heart-beating donation (group A) after 30minutes (group B) or 60minutes (group C) (n=5/group) of warm ischemia. After 8hours of NEVKP, contralateral kidneys were resected, grafts were autotransplanted, and the pigs were followed for 3days. After transplantation, renal function measured based on peak serum creatinine differed significantly among groups (P<.05). Throughout NEVKP, intrarenal resistance was lowest in group A and highest in group C (P<.05). intrarenal resistance at the initiation of NEVKP correlated with postoperative renal function (P<.001 at NEVKP hour 1). Markers of acid-base homeostasis (pH, HCO3- , base excess) differed among groups (P<.05) and correlated with posttransplantation renal function (P<.001 for pH at NEVKP hour 1). Similarly, lactate and aspartate aminotransferase were lowest in noninjured grafts versus donation after circulatory death kidneys (P<.05) and correlated with posttransplantation kidney function (P<.001 for lactate at NEVKP hour 1). In conclusion, assessment of perfusion characteristics and clinically available perfusate biomarkers during NEVKP allows the prediction of posttransplantation graft function. Thus, NEVKP might allow decision-making regarding whether grafts are suitable for transplantation.

Re: Big Data, Predictive Analytics, and Quality Improvement in Kidney Transplantation: A Proof of Concept.

No AccessJournal of UrologyUrological Survey1 Nov 2017Re: Big Data, Predictive Analytics, and Quality Improvement in Kidney Transplantation: A Proof of Concept David A. GoldfarbMD David A. GoldfarbDavid A. Goldfarb More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.08.014AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Re: Big Data, Predictive Analytics, and Quality Improvement in Kidney Transplantation: A Proof of Concept." The Journal of Urology, 198(5), p. 970 © 2017 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 198Issue 5November 2017Page: 970 Advertisement Copyright & Permissions© 2017 by American Urological Association Education and Research, Inc.MetricsAuthor Information David A. Goldfarb More articles by this author Expand All Advertisement PDF downloadLoading ...

Big Data, Predictive Analytics, and Quality Improvement in Kidney Transplantation: A Proof of Concept.

We sought proof of concept of a Big Data Solution incorporating longitudinal structured and unstructured patient-level data from electronic health records (EHR) to predict graft loss (GL) and mortality. For a quality improvement initiative, GL and mortality prediction models were constructed using baseline and follow-up data (0-90 days posttransplant; structured and unstructured for 1-year models; data up to 1 year for 3-year models) on adult solitary kidney transplant recipients transplanted during 2007-2015 as follows: Model 1: United Network for Organ Sharing (UNOS) data; Model 2: UNOS & Transplant Database (Tx Database) data; Model 3: UNOS, Tx Database & EHR comorbidity data; and Model 4: UNOS, Tx Database, EHR data, Posttransplant trajectory data, and unstructured data. A 10% 3-year GL rate was observed among 891 patients (2007-2015). Layering of data sources improved model performance; Model 1: area under the curve (AUC), 0.66; (95% confidence interval [CI]: 0.60, 0.72); Model 2: AUC, 0.68; (95% CI: 0.61-0.74); Model 3: AUC, 0.72; (95% CI: 0.66-077); Model 4: AUC, 0.84, (95 % CI: 0.79-0.89). One-year GL (AUC, 0.87; Model 4) and 3-year mortality (AUC, 0.84; Model 4) models performed similarly. A Big Data approach significantly adds efficacy to GL and mortality prediction models and is EHR deployable to optimize outcomes.

Improvement in kidney transplantation in the Balkans after the Istanbul Declaration: where do we stand today?

Due to the limited access to kidney transplantation (KTx) in developing countries, desperate patients have engaged in the purchase and sale of kidneys. In 2004, the World Health Assembly urged member states to protect the poor and vulnerable from being exploited through practices of illegal organ trafficking that had become widespread throughout the world. In 2008, the international transplant community convened a summit of transplant professionals, legal experts and ethicists to combat organ trafficking, transplant tourism and transplant commercialism that resulted in the Declaration of Istanbul (DOI). The South-Eastern Europe Health Network (SEEHN) represents a nine country multigovernmental collaboration on health systems. The Regional Health Development Centre on Organ Donation and Transplant Medicine (RHDC) was established in 2011 in Croatia to facilitate cooperation among south-eastern European countries to improve organ transplantation within the Balkan region. Since 2011, a collaboration between the RHDC, the Custodian Group of the DOI (DICG) and SEEHN professionals has enhanced strategic planning and definition of country-specific action plan priorities on organ donation and transplantation. Data of kidney transplantation provided in this report show a significant increase in transplantation activities in a 4-year period in Macedonia, Moldova, Bosnia and Hercegovina, Romania and Montenegro. The success of the donation and transplantation programmes was influenced by the engagement of key professionals and the establishment of organizational infrastructure with the implementation of an appropriate funding model. In conclusion, the DOI has provided an ethical framework for engagement of health professionals from south-eastern European countries. The newly established SEEHN RHDC as a technical coordinating body greatly contributed in building institutional capacity and strengthening regional collaboration between health authorities and professionals within these countries for improvement of transplant activities in the Balkans.

Should Pulsatile Preservation Be the Gold Standard in Kidney Transplantation?

In recent years, dramatic improvements in kidney transplantation, together with a rising incidence of diseases such as diabetes, have led to an increasing demand for deceased donor kidneys for transplantation. Hence, it has been necessary to expand the kidney donor pool by using organs once considered unsuitable for transplantation. These higher risk kidneys are typically from older donors with additional comorbidities and are more susceptible to injury. Therefore, the transplant community has been focusing efforts in trying to improve the outcomes of these high-risk organs. Preservation by pulsatile machine perfusion has been associated with decreased risk of delayed graft function and renoprotective effects on deceased donor kidneys. The aim of this review is to provide an overview of the principles of this preservation technique and to review the evidence regarding its usage for deceased donor kidneys compared to standard static cold storage.

Homoarginine and Clinical Outcomes in Renal Transplant Recipients: Results From the Assessment of Lescol in Renal Transplantation Study.

Despite improvements in kidney transplantation, complications, including cardiovascular morbidity and graft loss, contribute to reduced graft and patient survival. The amino acid homoarginine exerts a variety of beneficial effects that may be relevant for cardiovascular and graft outcomes, which is investigated in the present study. Homoarginine was measured in 829 renal transplant recipients participating in the placebo group of the Assessment of Lescol in Renal Transplantation study. Mean follow-up was 6.7 years. By Cox regression analyses, we determined hazard ratios (HRs) to reach prespecified, adjudicated endpoints according to baseline homoarginine levels: major adverse cardiovascular events (n = 103), cerebrovascular events (n = 53), graft failure or doubling of serum creatinine (n = 140), noncardiovascular mortality (n = 51), and all-cause mortality (n = 107). Patients mean age was 50 ± 11 years, homoarginine concentration was 1.96 ± 0.76 μmol/L, and 65% were men. Patients in the lowest homoarginine quartile (<1.40 μmol/L) had an adjusted 2.6-fold higher risk of cerebrovascular events compared to those in the highest quartile (>2.34 μmol/L) (HR, 2.56; 95% confidence interval [95% CI], 1.13-5.82). Similarly, the renal endpoint occurred at a significantly increased rate in the lowest homoarginine quartile (HR, 2.34; 95% CI, 1.36-4.02). For noncardiovascular and all-cause mortality, there was also increased risk associated with the lowest levels of homoarginine, with HRs of 4.34 (95% CI, 1.63-10.69) and 2.50 (95% CI, 1.38-4.55), respectively. Low homoarginine is strongly associated with cerebrovascular events, graft loss and progression of kidney failure and mortality in renal transplant recipients. Whether interventions with homoarginine supplementation improve clinical outcomes requires further evaluation.

Improvements in kidney transplantation from donors after cardiac death

To reduce the growing waiting list for kidney transplantation, we explored the limits of kidney transplantation from donors after cardiac death by liberally accepting marginal donor kidneys for transplantation. As the percentage of primary non-function (PNF) increased, we evaluated our transplantation program and implemented changes to reduce the high percentage of PNF in 2005, followed by a second evaluation over the period 2006-2009. Recipients of a kidney from a donor after cardiac death between 1998 and 2005 were analyzed, with PNF as outcome measure. During the period 2002-2005, the percentage of PNF increased and crossed the upper control limits of 12% which was considered as unacceptably high. After implementation of changes, this percentage was reduced to 5%, without changing the number of kidney transplantations from donors after cardiac death. Continuous monitoring of the quality of care is essential as the boundaries of organ donation and transplantation are sought. Meticulous donor, preservation, and recipient management make extension of the donor potential possible, with good results for the individual recipient. Liberal use of kidneys from donors after cardiac death may contribute to a reduction in the waiting list for kidney transplantation and dialysis associated mortality.

Steroid and Calcineurin Inhibitor—Sparing Protocols in Kidney Transplantation

Recent improvements in kidney transplantation have been driven largely by lower acute rejection rates attributed to better immunosuppressive agents. In an effort to reduce the long-term toxicities of immunosuppressant drugs, corticosteroid- and calcineurin inhibitor (CNI)–sparing immunosuppression protocols have become increasingly popular in managing kidney transplant recipients. Nevertheless, these strategies may increase the risk of acute and chronic allograft injury (CAI) that may worsen the fate of transplant recipients. This article focuses on steroid and CNI sparing protocols to elucidate their safety and efficacy in patients receiving a kidney transplant. Steroid avoidance protocols are rapidly and increasingly being used. Studies have shown that corticosteroids are not essential to achieve excellent short- and intermediate-term results. However, the role of steroid withdrawal is only marginally beneficial and very often benefit overstated. CNI-sparing strategies have been used to help maintain the balance between allograft survival and nephrotoxicity. Trials evaluating CNI minimization have shown reduced incidence of CAI and preservation of allograft function. CNI withdrawal within 3 to 12 months after kidney transplantation improved graft function despite increased risk of acute rejection. This approach may be feasible with adequate exposure and proper usage of mammalian target of rapamacin inhibitors. Late withdrawal or conversion did not show a clear benefit. Timing and degree of renal dysfunction are key determining factors. With regards to CNI avoidance, earlier trials, such as the Symphony study, did not support the use of a CNI-free regimen of low-dose sirolimus as initial immunosuppression. However, recent studies using costimulatory blockade-based immusouppression showed that CNI avoidance is possible. The best maintenance immunosuppressive with CNI- or steroid-sparing is a work in progress and awaits longer term follow-up. The availability of newer biologics for costimulatory blockade and new immunosuppressive agents with novel mechanisms of action have the potential of using CNI- and steroid-sparing protocols to minimize the incidence of CAI and improve long-term outcomes in kidney transplant recipients.

Patients' priorities for health research: focus group study of patients with chronic kidney disease

The inclusion of consumer preferences in prioritizing research topics is widely advocated, but prioritization is driven largely by professional agendas. Patients with chronic kidney disease (CKD) were purposively sampled from four kidney dialysis and transplant centres in Australia to participate in nine focus groups (three each for pre-dialysis, dialysis and transplant patients), which were conducted from July 2006 to September 2006. Each involved 6-8 participants. Transcripts were coded and thematically analysed to identify recurrent research topics and the participants' reasons for their choices. Participants suggested eight research priorities: prevention of kidney disease, better access to and improvement in kidney transplantation, reduction of symptoms of CKD and complications associated with treatment, new technological therapies, psychosocial aspects of living with CKD, whole body not organ-specialized care, and improvement in dialysis and caregiver support. Five major reasons for the selections were identified: normalization of life (developing therapies and regimens that fit into daily living), altruism (considering the welfare of others before personal needs), economic efficiency (channelling resources for maximum economic gain), personal needs (preferences based on feelings, values, personal needs) and clinical outcomes (improving health states and the physiological condition of patients with CKD). A patient-focused research agenda is possible to elicit for CKD, and by inference for other healthcare issues. Unlike researchers who focus on specific interventions and questions, consumers think in terms of broad themes and quality of life outcomes. Effective methods for translating a patient-focused agenda into research priority setting and resource allocation are now needed.

Long-Term Trends in Allograft Survival

Kidney transplantation has changed dramatically over the past decade. Many advances have occurred that result in shorter hospital stays, decreased acute rejection, less infectious morbidity, and improved long-term allograft survival. Many factors are responsible for the improvement in kidney transplantation, and these factors are discussed in this review. These successes have led to a paradox in the care of the kidney-transplant recipient, however. As the short-term complications are prevented or successfully managed, more patients will develop chronic problems with the function of the allograft.

Past, Present, and Future of Artificial Kidney Treatment

Abstract The past has seen the evolution of hemodialysis from a very complex operation to a systematized approach which allows the procedure to be instituted by minimally trained individuals. The first big advance in the application of hemodialysis to the problem of chronic renal insufficiency came in 1960 when a permanently implanted arteriovenous plastic fistulae was established. Improvements in dialyzer design and the logistics of hemodialysis since then have resulted in expansion of hemodialysis facilities. There is still a deficit between facilities available and suitable patients in need of therapy. Closure of this gap will depend upon a cheap, small, disposable dialyzer which most patients can operate themselves. In addition, an improvement in kidney transplantation results will remove many patients from the pool of those needing hemodialysis. It is likely that other medical applications of hemodialysis will be discovered in the future.