From Science Codex
National underutilization of preemptive and early kidney transplants
ROCHESTER, Minn. -- A kidney transplant is a life-changing and life-saving procedure. Yet, a new study conducted by Mayo Clinic and the University of Michigan shows that only one-third of patients who ultimately receive a living donor kidney transplant receive it pre-emptively (i.e., before starting dialysis). Less than two-thirds receive a transplant either pre-emptively or within a year of starting dialysis.
Existing research suggests that less time spent on dialysis before transplant can improve patient outcomes and survival after transplant. However, this new research shows there has been no increase in the utilization of what is known as timely living donor kidney transplants, which includes pre-emptive and early transplants, since 2006. The study "Under-utilization of timely kidney transplants in those with living donors," was published recently in the American Journal of Transplantation.
"Early referral to transplant evaluation and access to information about living donor kidney transplantation is key to a successful timely transplant and to improved long-term outcomes," says Mark Stegall, M.D., a professor of surgery at Mayo Clinic and senior author of the manuscript. "One important area where people lack education is on how to communicate with family and friends about their need for a kidney transplant and the fact that live donors offer, on average, a better outcome than deceased donor transplantation."
"Past studies and patient data have shown that we can improve a person's quality of life and chance of surviving end-stage renal disease if we can avoid or minimize the amount of time they spend on dialysis," says Ankit Sakhuja, M.B.B.S., a graduate of Mayo Clinic Renal Transplant Fellowship. He also currently is an assistant professor and director of the kidney paired donation program in the Division of Nephrology at the University of Michigan.
Mayo Clinic and University of Michigan researchers examined data from the United Network for Organ Sharing to evaluate the use of timely kidney transplants from 2000 to 2012 for 68,128 patients who received living donor transplants. Although data showed an improvement in the use of pre-emptive and early living donor transplants between 2000 and 2006, there has been no improvement since.
"Patients who are receiving transplants from compatible living donors should, theoretically, not need to go on dialysis at all," says Dr. Sakhuja. "In comparison, patients with no living donors may wait for a deceased donor organ for a long time. But in reality, we see a wide variation in the timing of transplants and no improvement in the use of timely transplants from living donors, despite the potential availability and known benefits."
Factors that influence a person's chance of receiving a timely living kidney transplant are thought to include lack of available living donors, decreased number of living donors, lack of insurance, lack of education or knowledge, delayed diagnosis and delayed referral.
Paired donations and direct donation represent two viable and available options for timely living kidney transplant. Yet both can be influenced by early referral and by a patient's understanding of their situation and the transplant evaluation process. The use of timely kidney transplant can vary greatly from one transplant center to another, based on factors including the patient population, the transplant team and its comfort in evaluating living donors, and providing prompt transplant evaluations for patients. But according to Dr. Stegall, approximately 80 percent of kidney transplants at Mayo Clinic in the past 15 years have been from living donors, with 40 percent of those being pre-emptive living donor transplants.
James Zimmerman and his oldest daughter, Jordyn, who also suffers from PKD.
A Santa Clarita man is in need of a kidney after three potential donors were turned away during the strict medical screening process.
The family of James Zimmerman has been impacted severely by polycystic kidney disease, or PKD, with no rescue in sight. His grandmother, mother and sister died of the disease while he, his uncle and his daughter are all suffering under PKD today.
“He has gone into stage four renal failure,” said Vicci Zimmerman, his wife of 25 years. “Our only hope is a living donor.”
An average adult kidney is about the size of a clenched fist, but Zimmerman’s kidneys are much larger, each one estimated to weigh about 22 pounds. This is because PKD produces large cysts on a kidney, filled with toxic fluid that makes it impossible to drain them or remove the excess.
“His kidneys are unable to process out the toxins from his blood,” Vicci Zimmerman said. “Water gives him heartburn at this point.”
James desperately needs a functioning kidney, but due to the strict screening process and his own O blood-type, no donor has been able to give him one.
Donating a kidney does not impact a donor’s life, said Vicci Zimmerman. And the costs are all taken care of by insurance.
She added that for most people, they can return to work the week after donating a kidney.
However, if no kidney is found for James Zimmerman in the next few months, he must undergo dialysis to continue cleaning his blood.
He is currently on schedule to start dialysis in the next few months, his wife said, sometime in April.
However, if Zimmerman does go on dialysis, his chances for a successful kidney transplant are reduced significantly.
“You have a much better chance of not rejecting a kidney without dialysis,” said Vicci Zimmerman. “But I only know to be positive.”
Those interested in seeing if they are able to donate can do so by email.
From Renal and Urology News
Polycystic Kidney Disease Raises Atrial Fibrillation Risk
Patients with polycystic kidney disease (PKD) are at elevated risk of new-onset atrial fibrillation (AF), according to researchers.
In a population-based cohort study using inpatient claims data from Taiwan's National Health Insurance Research Database (NHIRD), investigators found that PKD patients had a significant 31% increased risk of AF compared with individuals who did not have PKD, after adjusting for age, sex, and comorbidities. The risk was higher in patients aged 50 to 64 years and those without any comorbidities, “suggesting that the development of AF in patients with PKD is highly associated with the disease itself,” the investigators reported in Medicine (2016;95:e2623).
The study by Tung-Min Yu, MD, of the China Medical University in Taiwan, and colleagues compared 7,203 PKD patients with 28,739 randomly selected controls frequency matched according to age, sex, and baseline comorbidities. The risk of AF in PKD patients increased as the number of risk factors increased. Compared with patients with no risk factors, those with 1 risk factor had a significant 59% increased risk of AF. Patients with 3 risk factors had a significant 67% increased risk. Patients with 4 and 5 or more risk factors had a 2.2 and 3.6 times increased risk, respectively.
PKD patients with congestive heart failure (CHF) and chronic kidney disease (CKD) had the highest risk of AF, followed by PKD patients with hypertension and CHF, and PKD patients with hypertension, CHF, and CKD, according to the researchers. In addition, the odds of dying from AF was 69% higher in the PKD patients than in the comparison cohort. [Read more]
From Nursing in Practice, BY HELEN ROSE , JACQUELINE ANNAND
Managing chronic kidney disease in primary care
Key learning points:
– Chronic kidney disease is a common condition that is frequently encountered in primary care
– Primary care nurses are in a prime position to identify those at risk of chronic kidney disease and its complications
– It is often associated with otherlifestyle related long-term conditions and a significant opportunity exists to provide education and monitoring to prevent progression to end stage renal failure
Chronic kidney disease (CKD) is defined as an abnormality of kidney function or structure present for more than three months,1 and has been increasingly recognised as a significant global public health problem.2,3,4
Since estimated glomerular filtration rate (eGFR) recording was implemented on all urea and electrolyte blood samples in the UK in 2006, the scale of the problems has become clearer.5 Attention has been increasingly focused on early stage disease management in an attempt to slow or prevent progression to renal failure and modify associated cardiovascular risk.1,6
UK prevalence rates are estimated to be around 6-8%, and increase with age, diabetes mellitus and cardiovascular disease.3,4 Only around 4% of individuals with early CKD will progress to requiring dialysis treatment. However, it is estimated that a much larger proportion, around 46% will suffer mortality over a five year period due to related cardiovascular events.1
Causes
Underlying disease processes in CKD are various and wide ranging, the disease is often found alongside a number of other long-term conditions such as diabetes mellitus and cardiovascular disease, conditions that both have the potential to lead to renal damage.
There are a number of primary renal diseases and multisystem diseases, such as Immunoglobulin A (IgA) nephropathy, lupus and vasculitis that can cause inflammation and damage to the glomerular tissue in the kidney.
Underlying urological conditions can also lead to CKD obstructions caused by congenital malformations of the urinary tract, prostatic enlargement and renal calculi can all be indicated in the development of CKD. In addition, there are a number of hereditary conditions such as polycystic kidney disease, alports syndrome that can lead to CKD.7
Signs and symptoms
Table 1 outlines the stages of CKD and the symptoms and complications associated with each stage. It is important to remember that mild to moderate CKD often produces very little in the way of symptoms. It’s usually identified by the presence of protein in the urine or by elevated blood creatinine levels. Therefore it is important that those at increased risk of CKD development such as individuals with diabetes and hypertension are screened vigilantly for signs of CKD development. This includes monitoring of urea and electrolytes (Us and Es) for signs of creatinine rise or fall in eGFR, and urinalysis and urinary albumin creatinine ratio (ACR) for signs of microproteinuria development.1,8
In stage 4-5 the individual may start to complain of symptoms of nausea, extreme fatigue, loss of appetite, itching and shortness of breath. Oedema may be noted.
From Renal and Urology News
Polycystic Kidney Disease Raises Atrial Fibrillation Risk
In a population-based cohort study using inpatient claims data from Taiwan's National Health Insurance Research Database (NHIRD), investigators found that PKD patients had a significant 31% increased risk of AF compared with individuals who did not have PKD, after adjusting for age, sex, and comorbidities. The risk was higher in patients aged 50 to 64 years and those without any comorbidities, “suggesting that the development of AF in patients with PKD is highly associated with the disease itself,” the investigators reported in Medicine (2016;95:e2623).
The study by Tung-Min Yu, MD, of the China Medical University in Taiwan, and colleagues compared 7,203 PKD patients with 28,739 randomly selected controls frequency matched according to age, sex, and baseline comorbidities. The risk of AF in PKD patients increased as the number of risk factors increased. Compared with patients with no risk factors, those with 1 risk factor had a significant 59% increased risk of AF. Patients with 3 risk factors had a significant 67% increased risk. Patients with 4 and 5 or more risk factors had a 2.2 and 3.6 times increased risk, respectively.
PKD patients with congestive heart failure (CHF) and chronic kidney disease (CKD) had the highest risk of AF, followed by PKD patients with hypertension and CHF, and PKD patients with hypertension, CHF, and CKD, according to the researchers. In addition, the odds of dying from AF was 69% higher in the PKD patients than in the comparison cohort. [Read more]
Key learning points:
– Chronic kidney disease is a common condition that is frequently encountered in primary care
– Primary care nurses are in a prime position to identify those at risk of chronic kidney disease and its complications
– It is often associated with otherlifestyle related long-term conditions and a significant opportunity exists to provide education and monitoring to prevent progression to end stage renal failure
Chronic kidney disease (CKD) is defined as an abnormality of kidney function or structure present for more than three months,1 and has been increasingly recognised as a significant global public health problem.2,3,4
Since estimated glomerular filtration rate (eGFR) recording was implemented on all urea and electrolyte blood samples in the UK in 2006, the scale of the problems has become clearer.5 Attention has been increasingly focused on early stage disease management in an attempt to slow or prevent progression to renal failure and modify associated cardiovascular risk.1,6
UK prevalence rates are estimated to be around 6-8%, and increase with age, diabetes mellitus and cardiovascular disease.3,4 Only around 4% of individuals with early CKD will progress to requiring dialysis treatment. However, it is estimated that a much larger proportion, around 46% will suffer mortality over a five year period due to related cardiovascular events.1
Causes
Underlying disease processes in CKD are various and wide ranging, the disease is often found alongside a number of other long-term conditions such as diabetes mellitus and cardiovascular disease, conditions that both have the potential to lead to renal damage.
There are a number of primary renal diseases and multisystem diseases, such as Immunoglobulin A (IgA) nephropathy, lupus and vasculitis that can cause inflammation and damage to the glomerular tissue in the kidney.
Underlying urological conditions can also lead to CKD obstructions caused by congenital malformations of the urinary tract, prostatic enlargement and renal calculi can all be indicated in the development of CKD. In addition, there are a number of hereditary conditions such as polycystic kidney disease, alports syndrome that can lead to CKD.7
Signs and symptoms
Table 1 outlines the stages of CKD and the symptoms and complications associated with each stage. It is important to remember that mild to moderate CKD often produces very little in the way of symptoms. It’s usually identified by the presence of protein in the urine or by elevated blood creatinine levels. Therefore it is important that those at increased risk of CKD development such as individuals with diabetes and hypertension are screened vigilantly for signs of CKD development. This includes monitoring of urea and electrolytes (Us and Es) for signs of creatinine rise or fall in eGFR, and urinalysis and urinary albumin creatinine ratio (ACR) for signs of microproteinuria development.1,8
In stage 4-5 the individual may start to complain of symptoms of nausea, extreme fatigue, loss of appetite, itching and shortness of breath. Oedema may be noted.
[Read more]
Horrific kidney disease blights generations of Wetherby woman's family
For Boston Spa mother-of-two, Jayne Dryden, her entire life has been spent watching on helplessly as her loved-ones battle a horrific and hereditary kidney disease.
Polycystic kidney disease (PKD) has defined Jayne’s life, from watching her mother battle the inherited condition to finding out at just 21-years-old that she had also developed the disorder.
Now 52, Jayne spends three days of her week on dialysis, for four hours a time to treat the disease, but she is not alone in her struggles.
Five of her mother’s ten brothers and sisters have undergone kidney transplants and only one of Jayne’s three siblings has been fortunate enough to avoid inheriting the condition.
And, just like her mother did, Jayne will have her son and daughter succumb to the disease after tests revealed they had not managed to escape the powerful gene.
Despite the disease, Jayne is still managing to keep up her full-time job but admits she is finding it ‘harder and harder’ to live a normal life as her condition deteriorates.
She said: “My mum started dialysis when she was 51 but after seven years my dad was able to give her one of his kidneys. Unfortunately it only lasted for about seven years before it gave up.
“She’s back on dialysis now and in October I was forced to start as well. My kidney function was at 11 per cent, then down to nine but when it got to six my doctor told me it was time.
“The process is gruesome and there are points when you think ‘why is this happening to us?’. It’s very upsetting and it really has defined our family.”
However, Jayne explained that having the condition never made her doubt her decision to try for children but was fully aware the odds were stacked against them.
Polycystic Kidney Disease is the world’s most common inherited kidney disease which affected between one in 400 and one in 1000 people worldwide. [Read more]
Recommendations Issued for Tolvaptan Use in ADPKD
In May 2015, the European Medicines Agency approved the use of tolvaptan, a vasopressin V2 receptor antagonist, for slowing progression of cyst development and renal insufficiency in adult ADPKD patients with CKD stages 1–3 at initiation of treatment and evidence of rapidly progressing disease. This makes tolvaptan the first pharmaceutical agent approved for slowing disease progression in ADPDK. Tolvaptan was originally approved for the treatment of hyponatremia, and in the United States, it is only approved for that use. The FDA in 2014 asked for additional efficacy and safety data.
The recommendations are based on the consensus of ADPKD experts and methodologists in the ERA-EDTA Working Groups on Inherited Kidney Disorders and European Renal Best Practice. In the consensus document, which was published online in Nephrology Dialysis Transplantation (NDT), the ERA-EDTA suggests that tolvaptan can be prescribed to adult ADPKD patients younger than 50 years with CKD stages 1–3a (an estimated glomerular filtration rate [eGFR] greater than 45 mL/min/1.73 m2) who have demonstrated or who are likely to have rapidly progressing disease.
ERA-EDTA recommends not starting tolvaptan in patients aged 30–40 years with CKD stage 1 (eGFR greater than 90 mL/min/1.73 m2) or patients aged 40–50 years with CKD stages 1 or 2 (eGFR greater than 60 mL/min/1.73 m2).
The organization recommends that rapid disease progression be defined as a confirmed annual eGFR decline of at least 5 mL/min/1.73 m2 in 1 year, and/or at least 2.5 mL/min/1.73 m2 per year over a period of 5 years. It can also be defined as a greater than 5% increase in total kidney volume per year by repeated measurements (preferably 3 or more, each at least 6 months apart and by magnetic resonance imaging).
With regard to dosing, ERA-EDTA suggests that tolvaptan be started with a dose of 45 mg in the morning and 15 mg in the evening, uptitrating the dose to 50/30 and 90/30 when tolerated, and discontinuing tolvaptan when patients approach end-stage renal disease.
From Ripon Gazette, United Kingdom, by Dan Windham
For Boston Spa mother-of-two, Jayne Dryden, her entire life has been spent watching on helplessly as her loved-ones battle a horrific and hereditary kidney disease.
Polycystic kidney disease (PKD) has defined Jayne’s life, from watching her mother battle the inherited condition to finding out at just 21-years-old that she had also developed the disorder.
Now 52, Jayne spends three days of her week on dialysis, for four hours a time to treat the disease, but she is not alone in her struggles.
Five of her mother’s ten brothers and sisters have undergone kidney transplants and only one of Jayne’s three siblings has been fortunate enough to avoid inheriting the condition.
And, just like her mother did, Jayne will have her son and daughter succumb to the disease after tests revealed they had not managed to escape the powerful gene.
Despite the disease, Jayne is still managing to keep up her full-time job but admits she is finding it ‘harder and harder’ to live a normal life as her condition deteriorates.
She said: “My mum started dialysis when she was 51 but after seven years my dad was able to give her one of his kidneys. Unfortunately it only lasted for about seven years before it gave up.
“She’s back on dialysis now and in October I was forced to start as well. My kidney function was at 11 per cent, then down to nine but when it got to six my doctor told me it was time.
“The process is gruesome and there are points when you think ‘why is this happening to us?’. It’s very upsetting and it really has defined our family.”
However, Jayne explained that having the condition never made her doubt her decision to try for children but was fully aware the odds were stacked against them.
Polycystic Kidney Disease is the world’s most common inherited kidney disease which affected between one in 400 and one in 1000 people worldwide. [Read more]
PKD Treatment
From Renal and Urology News
The recommendations are based on the consensus of ADPKD experts and methodologists in the ERA-EDTA Working Groups on Inherited Kidney Disorders and European Renal Best Practice. In the consensus document, which was published online in Nephrology Dialysis Transplantation (NDT), the ERA-EDTA suggests that tolvaptan can be prescribed to adult ADPKD patients younger than 50 years with CKD stages 1–3a (an estimated glomerular filtration rate [eGFR] greater than 45 mL/min/1.73 m2) who have demonstrated or who are likely to have rapidly progressing disease.
ERA-EDTA recommends not starting tolvaptan in patients aged 30–40 years with CKD stage 1 (eGFR greater than 90 mL/min/1.73 m2) or patients aged 40–50 years with CKD stages 1 or 2 (eGFR greater than 60 mL/min/1.73 m2).
The organization recommends that rapid disease progression be defined as a confirmed annual eGFR decline of at least 5 mL/min/1.73 m2 in 1 year, and/or at least 2.5 mL/min/1.73 m2 per year over a period of 5 years. It can also be defined as a greater than 5% increase in total kidney volume per year by repeated measurements (preferably 3 or more, each at least 6 months apart and by magnetic resonance imaging).
With regard to dosing, ERA-EDTA suggests that tolvaptan be started with a dose of 45 mg in the morning and 15 mg in the evening, uptitrating the dose to 50/30 and 90/30 when tolerated, and discontinuing tolvaptan when patients approach end-stage renal disease.
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