Long-term outcomes during 37 years of pediatric kidney transplantation: a cohort study comparing ethnic groups
Miriam DavidovitsLewis ReismanRoxana CleperN Bar-NathanIrit KrauseAmit DaganNeomi ZanhendlerGabriel ChodickOsnat HochermanMaya MorSigal AisnerEytan Mor
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<i>Background:</i> Some patients who reach end-stage renal disease refuse to start dialysis at the time suggested by their nephrologist and delay it. Whether this delay may affect health-related quality of life (HRQoL), clinical and biological parameters at dialysis onset, and then survival and hospitalization during dialysis is unknown. <i>Methods:</i> We considered all adult patients who began dialysis in Lorraine (France) in 2005–2006 having previously been followed by a nephrologist. Clinical and biological characteristics at dialysis onset were collected from medical records, and nephrologists were interviewed about compliance with the recommended starting date. HRQoL was measured using the French version of the ‘Kidney Disease Quality of Life’ V36 questionnaire. Mortality and total duration of hospitalization during the first year of dialysis were recorded as part of the end-stage renal disease French registry. The effects of delaying dialysis on survival and on duration of hospitalization were determined using log-rank test and polychotomous logistic regression, respectively. <i>Results:</i> Of 541 patients, 88 (16.3%) declined to initiate dialysis at the time recommended by the nephrologist and delayed it. Compared with patients who were compliant with the advice, noncompliers had more comorbidities, poorer clinical and biological profiles at dialysis start, and a higher risk of beginning dialysis in emergency circumstances with greater decline in the ‘burden of kidney disease’ dimension of HRQoL. However, there were no differences in survival or duration of hospitalization during dialysis. <i>Conclusion:</i> Despite a negative effect on clinical and biological parameters at initiation, delaying dialysis did not impact on survival during treatment.
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Home dialysis modalities are underutilized in the USA with only 8% of the dialysis patients undergoing renal replacement therapy at home versus 92% being treated with center hemodialysis. This is in contrast to the nephrology professionals' opinion about the best dialysis therapy and their potential choice in the hypothetical situation of choosing a dialysis modality for themselves. Pre-dialysis education changes the distribution of dialysis modality significantly, as 50% of informed patients choose home dialysis. Close collaboration among nephrology professionals, patients and providers is required to make home therapy a reality for any interested patient.
Nephrology
Home dialysis
Renal replacement therapy
Home hemodialysis
Treatment modality
Modalities
Modality (human–computer interaction)
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Preemptive kidney transplantation (preKT) is associated with higher patient survival, improved quality of life, and lower costs. However, only a minority of patients receives preKT. The aim of this study was to examine changes over the past decade in rates of preKT, focusing on living donor kidney transplantation (LDKT) and specifically recipients who underwent kidney transplantation within 1 year of initiating dialysis.Using United Network of Organ Sharing data, we examined retrospectively all kidney transplant candidates (n = 369 103) and recipients (n = 141 254) from 2003 to 2012 in the United States focusing on LDKT (n = 47 108). Predictors of preKT were examined, and patient and graft survival were compared for preKT, pretransplant dialysis less than 1 year, and pretransplant dialysis recipients of 1 year or longer.PreKT occurred in only 17% of recipients overall and 31% of LDKT recipients. Medicare patients (odds ratio [OR], 0.29; 95% confidence interval [95% CI], 0.28-0.31), diabetics (OR, 0.75; 95% CI, 0.69-0.80), and minorities (Hispanics OR, 0.62; 95% CI, 0.57-0.68 and African Americans OR, 0.58; 95% CI, 0.53-0.63) were less likely to receive preKT. Dialysis recipients for less than 1 year comprised 30% of nonpreemptive LDKT. Dialysis recipients of less than 1 year had similar patient survival to preKT (5 years: preKT, 94%; dialysis < 1 year, 94%; dialysis ≥ 1 year, 89%; P < 0.01), but decreased death-censored graft survival (5 years: preKT, 93%; dialysis < 1 year, 89%; and dialysis ≥ 1 year, 89%; P < 0.01).PreKT remains an unrealized goal for the majority of recipients. Medicare patients, diabetics, and minorities are less likely to receive preKT. Almost one third of nonpreemptive LDKT recipients were dialyzed for less than 1 year, highlighting an important target for improvement.
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Dialysis and kidney transplantation are the only available management approaches for these patients. Estimates show that the survival rates and quality of life are significantly higher for patients that receive kidney transplantation than others with dialysis. In addition, the effectiveness of preemptive kidney transplantation was well-evidenced in the literature. It had been further demonstrated that performing preemptive kidney transplantation significantly reduces the complications of renal transplantation and dialysis and was incredibly cost-effective when compared to dialysis. Furthermore, evidence regarding its effectiveness was well-established among studies in the literature as a safe primary management approach for patients suffering from end-stage kidney disease. This literature review discussed preemptive kidney transplantation's indications, outcomes and complications. Our findings indicated the efficacy of the approach for patients suffering from end-stage kidney disease. However, the appropriate selection of the patients was a critical issue. Besides, serious efforts should be exerted to prepare the patient perioperatively. Nevertheless, kidney functions were reported to increase following preemptive kidney transplantation. Graft rejection and delayed graft functions were also reported to follow preemptive kidney transplantation. However, the estimated rates are lower than those for patients having transplantation following the start of dialysis. We encourage further relevant investigations to further elaborate on the long-term findings, prognosis, and complications.
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STARRT recently demonstrated that many patients experience suboptimal dialysis starts (defined as initiation as an inpatient and/or with a central venous catheter), even when followed by a nephrologist for >12 months (NDT 2011). However, STARRT did not identify the factors associated with suboptimal initiation of dialysis. The objectives of this study were to extend the results of STARRT by ascertaining the factors leading to suboptimal initiation of dialysis in patients who were referred at least 12 months prior to commencement of dialysis. At each of the three Toronto centers, charts of consecutive incident RRT patients were identified from 1 January 2009 to 31 December 2010, with predetermined data extracted. A total of 436 incident RRT patients were studied; 52.4% were followed by a nephrologist for >12 months prior to the initiation of dialysis. Suboptimal starts occurred in 56.4% of these patients. No attempt at arteriovenous fistula (AVF) or arteriovenous graft (AVG) prior to initiation was made in 65% of these starts. Factors contributing to suboptimal starts despite early referral included patient-related delays (31.25%), acute-on-chronic kidney disease (31.25%), surgical delays (16.41%), late decision-making (8.59%) and others (12.50%). The percentage of optimal starts with early referral among 14 nephrologists ranged from 33 to 72%. Most patients started dialysis in a suboptimal manner, despite an extended period of pre-dialysis care. Nephrologists should take responsibility for suboptimal initiation of dialysis despite early referral and test methods that attempt to prevent this.
Nephrology
Central venous catheter
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Objective To evaluate the feasibility and advantages of kidney transplantation for uremic patients without prior dialysis. Methods The clinical data of 146 uremic patients who presented for kidney transplantation without prior dialysis were retrospectively analyzed and compared with those of 653 dialysis patients undergoing kidney transplantation. Results The incidence of hepatitis was 5. 48 % in the nonuse dialysis group and 19. 14 % in the dialysis group prior transplantation with the difference being significant. After transplantation, there was no significant difference in the time of plasma creatinine returning to normal level between the nonuse dialysis group and the dialysis group. One month after transplantation, the levels of hemoglobin and albumin in the nonuse dialysis group were not significantly different from those in the dialysis group. The acute rejection rate, DGF and hepatic function impairment rate were 19.18 %, 6. 16 %, 9.59 % in nonuse dialysis group, while 33.54 %, 13.02 %, 25.57 % in dialysis group respectively, with the difference being significant. There were no significant differences in infectious rate and hypertension rate between the two groups. The patient/graft 1-year survival rate in the nonuse dialysis group and the dialysis group was 98. 63 % and 97. 24 % respectively, and the patient/graft 3-year survival rate was 95. 95 % and 89. 20 % , respectively (all P0. 05). Conclusions The kidney transplantation without prior dialysis offered comparable patient/graft survival to kidney transplantation with prior dialysis and avoided the dialysis complications and sensitization of transfusion, while reduced the risk of acute rejection. Therefore, uremic patients may be considered to receive the kidney transplantation without prior dialysis in clinic.
Uremia
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The aim of the study was to determine and compare quality of life in patients with chronic kidney failure treated with dialysis and those after kidney transplantation.The group comprised 199 patients with chronic kidney failure (99 dialysis patients and 100 patients after kidney transplantation). Data were collected using the WHOQOL-BREF questionnaire for assessing quality of life. Patients after kidney transplantation had statistically significantly higher quality of life scores in all domains than dialysis patients (p < 0.001). When compared with the general population, patients after transplantation showed lower quality of life only in the physical health domain (p < 0.001) and separate item measuring satisfaction with health (p < 0.01). Dialysis patients had lower quality of life than the normal population in all domains and separate items, the only exception being the environment domain(p < 0.001). Dialysis patients quality of life significantly decreased in all domains with time from the initiation of dialysis therapy (p < 0.05).Information about QoL of patients with renal failure treated by different approaches may help both doctors and patients and their families when making decisions about therapy selection.
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