Preemptive Living Donor Transplantation Research Articles

The Concordance between Patients' Renal Replacement Therapy Choice and Definitive Modality: Is It a Utopia?

IntroductionIt is desirable for patients to play active roles in the choice of renal replacement therapy (RRT). Patient decision aid tools (PDAs) have been developed to allow the patients to choose the option best suited to their individual needs.Material and MethodsAn observational, prospective registry was conducted in 26 Spanish hospitals between September 2010 and May 2012. The results of the patients’ choice and the definitive RRT modality were registered through the progressive implementation of an Education Process (EP) with PDAs designed to help Chronic Kidney Disease (CKD) patients choose RRT.ResultsPatients included in this study: 1044. Of these, 569 patients used PDAs and had made a definitive choice by the end of registration. A total of 88.4% of patients chose dialysis [43% hemodialysis (HD) and 45% peritoneal dialysis (PD)] 3.2% preemptive living-donor transplant (TX), and 8.4% conservative treatment (CT). A total of 399 patients began RRT during this period. The distribution was 93.4% dialysis (53.6% HD; 40% PD), 1.3% preemptive TX and 5.3% CT. The patients who followed the EP changed their mind significantly less often [kappa value of 0.91 (95% CI, 0.86–0.95)] than those who did not follow it, despite starting unplanned treatment [kappa value of 0.85 (95% CI, 0.75–0.95]. A higher agreement between the final choice and a definitive treatment was achieved by the EP and planned patients [kappa value of 0.93 (95% CI, 0.89–0.98)]. Those who did not go through the EP had a much lower index of choosing PD and changed their decision more frequently when starting definitive treatment [kappa value of 0.73 (95% CI, 0.55–0.91)].ConclusionsFree choice, assisted by PDAs, leads to a 50/50 distribution of PD and HD choice and an increase in TX choice. The use of PDAs, even with an unplanned start, achieved a high level of concordance between the chosen and definitive modality.

Cost-effectiveness achieved through changing the composition of renal replacement therapy in Japan

Objective:The cost-effectiveness of renal replacement therapy (RRT) is affected by the composition of treatment. This study aimed to estimate the costs and outcomes associated with changing the composition of RRT modality over time.Methods:By using clinical and cost data from a systematic review, a Markov model was developed to assess the costs and benefits of the four main treatments available for RRT in Japan. The model included direct health service costs and quality-adjusted life years (QALY). Sensitivity analyses were performed to assess the robustness of the results.Results:Over the 15-year period of the model, the current composition of RRT (i.e., the base composition of RRT) was $84,008/QALY. The most cost-effective treatment was when the likelihood of a living donor transplant was increased by 2.4-times ($70,581/QALY). Compared with the base composition of RRT, dominant treatments with respect to cost-effectiveness were when the likelihood of a deceased donor transplant was increased by 22-times and when the likelihood of a pre-emptive living donor transplant was increased by 2.4-times. Little difference was found between these two treatments. One-way sensitivity analysis did not change the cost effectiveness except for costs of chronic hemodialysis and a living donor transplant in subsequent years.Limitations:It is difficult to increase the rate of transplant overall in the shorter term nationally and internationally.Conclusions:Appropriate distribution of all transplant options and hemodialysis is necessary to achieve the most cost-effective solution.

Enabling self-management: selecting patients for home dialysis?

Pre-emptive living donor transplantation should always be promoted as the first-line treatment for kidney failure. Where that is not possible, patients must receive timely information and advice regarding all dialysis options available, including home-based peritoneal dialysis and haemodialysis. Where a dialysis unit enables and actively encourages self-management, patients will tend to select themselves, and if well motivated may overcome significant difficulties to exceed the expectations or predictions of dialysis staff. Patients then become advocates themselves and can provide other patients with the necessary motivation to consider a home treatment, such that they approach staff, rather than vice versa. For staff to be able to talk to patients with confidence requires direct experience of home dialysis, but in units which do not have a full range of home therapies, this may initially be difficult. Visiting patients in their home environment is an essential part of training for both medical and nursing staff. Before a patient is able to begin to engage in discussion about any dialysis therapy, they must have reached a point of acceptance that dialysis is necessary. If they are not at this point, then any attempt at ‘education’ will be largely futile. Once a patient has arrived at the point of choosing a home therapy, the pathway to their first dialysis at home must be as smooth and problem-free as possible.

Preemptive transplantation and the transplant first initiative

Preemptive kidney transplant (PKT) is the focus of a new initiative, 'Transplant First'. This initiative focuses on increasing patient transition to transplantation prior to the need for dialysis. This review will evaluate the benefits of PKT and means to accomplish this goal. Outcomes data show PKT significantly improves long-term survival for the recipient and the allograft. In addition quality of life is improved. This also holds true for children and particularly for adolescents. In 2008, 5.7% of incident patients with end-stage renal disease were placed on the waiting list before beginning dialysis and 0.8% underwent preemptive living donor transplant before wait listing. If patients are evaluated before starting dialysis and are acceptable candidates, up to 40% will receive a preemptive transplant. Recent articles stress that patients want information from their physician; important impediments to PKT remain provider and patient education, insurance coverage and patient reluctance to ask for living donation. Preemptive transplant saves lives. Increased education focused on providers, patients and entire communities is key, as is an increase in living donation. Furthermore, to maximize the impact of transplant first, increased living donor protections and immunosuppression coverage for the life of the allograft are essential.

Children as receptors of living donors

The most important factor in life expectancy for children on renal replacement therapy (RRT) is to have a functioning graft when they reach adulthood (63 years  on transplantation vs 37 years on dialysis). The pediatric recipient is very suitable for a living donor transplantation (LDT), with few contraindications. There are several reasons that make LDT the most recommended RRT in children: pre-emptive transplant avoiding dialysis, good renal mass, minimal cold ischemia time, better HLA-matching and the possibility to program the time of surgery. Long term graft survival in LDT is significantly better than in cadaveric donor transplantation (CDT) (81.3%  LDT vs 60.8 % CDT at 10 years follow-up). Calculated half-life graft survival for recipients aged 2-5 years reaches 27.5 years in some series, making LDT the ideal option for these children. Adolescent recipients (12-17 years) have an excellent early graft survival, but the worst long term outcome compared with the rest of pediatric population. However, preemptive LDT has a 70% of graft survival at 10 years. Late rejections episodes associated with non-adherence factors are found in all series. Unrelated LDT in pediatric recipients outcome remain unclear.

Improving Preemptive Transplant Education to Increase Living Donation Rates: Reaching Patients Earlier in Their Disease Adjustment Process

Patients who receive a preemptive kidney transplant before starting dialysis avoid the medical complications related to dialysis and have the highest graft success and lowest mortality rates. Because only 2.5% of incident patients receive kidney transplants preemptively, improved psychosocial education may assist more patients in accessing preemptive transplant. This article outlines (1) unique psychosocial issues affecting patients with chronic kidney disease stage 4 (glomerular filtration rates > 20 mL/min per 1.73 m2) and (2) how an educational program about preemptive living donor transplant should be designed and administered to increase access to this treatment option. Early referral patients may be overwhelmed in coping with and learning about their disease and, therefore, not ready to make a treatment decision, or they may be highly motivated to obtain a transplant to avoid dialysis and return to a normal life. An education program that defines the quality-of-life and health benefits possible with early transplant is outlined. The program is focused on minimizing the disruption of starting 2 treatment techniques and maximizing early transplant health, graft survival, employability, and retention of insurance coverage. Once the benefits of preemptive living donor transplant are outlined, educators can focus on demystifying the living donor evaluation process and assisting interested patients in planning how to find a living donor. To reach all patients, especially racial minorities, education about preemptive transplant should be available in primary-care physicians' and community nephrologists' offices, at dialysis centers, and through other kidney organizations.

A Case of Desensitization, Transplantation, and Allograft Dysfunction

A 41-yr-old Asian-American woman presented for evaluation for a second kidney transplant in 2005. She had a potential living kidney donor, a sister. The patient had developed end-stage renal disease from IgA glomerulonephritis. This was first diagnosed in 1989; in 1991, she underwent a preemptive living donor transplant in another hospital. The donor was another sister and the allograft was a 2-haplotype match. Despite this, her early post-transplant course was complicated by severe acute rejection (further information on this was not available). She also developed mitral valve endocarditis with septic embolization to the brain and, in addition to prolonged antimicrobial therapy, required craniotomy and insertion of a prosthetic mitral valve. Fortunately, she made an excellent recovery. She was later diagnosed as having chronic allograft nephropathy and resumed peritoneal dialysis in 2005 and stopped immunosuppression at that time. She had received blood transfusions in the early period after her first transplant but had had no pregnancies. The only other medical history was hypertension. Her functional status was excellent. Examination was unremarkable apart from the prosthetic mitral valve click. Investigations showed the potential donor was a 1–2–2 human leukocyte antigen (HLA) mismatch with the potential recipient. The latter was blood group ABO-AB and had a panel reactive antibody (PRA) of 0% against class I HLA by the complement-dependent cytotoxicity (CDC) assay. However, by the more sensitive FlowPRA assay, the PRA against class I antigens was 35% and against class II antigens was 98%. The crossmatch against T cells of the potential donor was negative by the CDC (antihuman globulin) method but was strongly positive against B cells by the CDC (modified Amos) method: positive out to a 1:256 dilution The patient was diagnosed as being very highly sensitized to class II HLA antigens of the donor and informed that the transplant would …