"Weighing the Pros and Cons of Everything": A Qualitative Descriptive Study Exploring Perspectives About Living Donor Kidney Transplantation From Parents of Chinese Canadian Pediatric Patients With Chronic Kidney Disease.

Background: As of 2021, more than 6000 children and youth in Canada were living with end-stage kidney disease (ESKD), for which kidney transplantation is considered the preferred treatment by health professionals. Research shows that living donor kidney transplantation (LDKT) has superior allograft and recipient survival compared to deceased donor kidney transplantation (DDKT). However, in a pediatric setting, the choice of LDKT or DDKT is a summative consideration of factors weighed carefully by the patient's family, health care team, and patient. Decision-making surrounding transplantation may be more complex for racial and ethnic minorities as culturally specific values and beliefs are interwoven within dominant understandings and concepts of health and accepted models of health care. For example, Chinese Canadians have an increased risk of ESKD, yet reduced access to LDKT compared to White patients, despite being the largest visible minority population in Canada. Objective: The objective of this qualitative study is to deepen our understandings of the decision-making process surrounding DDKT versus LDKT among parents of Chinese Canadian pediatric patients with chronic kidney disease (CKD). Design: Qualitative descriptive study design. Setting: The Nephrology Program at The Hospital for Sick Children in Toronto, Canada. Participants: Caregivers of Chinese Canadian patients with CKD, 18 years of age or older, and who spoke English, Cantonese, or Mandarin. Methods: One-on-one, semistructured interviews were conducted virtually, by a member of the research team and were audio-recorded and transcribed verbatim. Thematic analysis was used to explore participants' shared experience. Results: Seven interviews were conducted with 6 mothers and 1 father of 6 Chinese Canadian pediatric patients with CKD: 4 patients had undergone a kidney transplant, and 2 were not yet listed for transplant. Analysis of data highlighted that cultural influences affected whether parents shared with others about their child's illness and experience. The cultural understanding that it is inappropriate to burden others contributed to the creation of an isolating experience for participants. Cultural influences also impacted whether parents asked others to be a living donor as participants articulated this would place a physical burden on the living donor (e.g., potential risk to their health) and an emotional burden on the participant as they would be indebted to a willing donor. Ultimately, parents' decision to choose DDKT or LDKT for their patient-child was a result of evaluating both options carefully and within an understanding that the ideal treatment choice reflected what was best for all family members. Limitations: Findings reflect experiences of a small sample from a single recruitment site which may limit transferability. Conclusions: Parents in this study felt that they had access to the necessary evidence-based information to make an informed decision about the choice of DDKT versus LDKT for their child. Participant narratives described feeling isolated within cultural communities of family and friends and participants' suggestion of benefiting from increased support may guide future research directions. Practitioners can offer direct and indirect support to families, with recognition of the importance of cultural values and family-centered care on decision-making within families. Opportunities are needed for accessible, virtual social support platforms to increase parental feelings of culturally mediated peer support from parents who share similar experiences.

Contexte: En 2021, plus de 6000 enfants et jeunes au Canada vivaient avec une insuffisance rénale terminale (IRT), une affection pour laquelle la transplantation rénale est considérée comme le traitement préférentiel par les professionnels de la santé. La recherche montre que la transplantation d'un rein de donneur vivant (TRDV) présente des taux de survie du greffon et du receveur supérieurs à ceux de la transplantation d'un rein de donneur décédé (TRDD). En contexte pédiatrique, le choix entre la TRDV et la TRDD fait l'objet d'une évaluation sommative de facteurs soigneusement pesés par le patient, sa famille et l'équipe de soins. La prise de décision entourant la transplantation peut s'avérer encore plus complexe pour les personnes issues des minorités raciales et ethniques, car des valeurs et croyances spécifiques à la culture sont imbriquées dans les conceptions et concepts dominants de la santé et les modèles de soins acceptés. Les Canadiens d'origine chinoise, par exemple, présentent un risque accru d'IRT, mais leur accès à la TRDV est réduit par rapport aux patients d'origine caucasienne, bien qu'ils constituent la plus importante minorité visible dans la population Canadienne. Objectif: L'objectif de cette étude qualitative est d'approfondir notre compréhension du processus décisionnel entourant le choix entre la TRDD et la TRDV chez les parents de patients pédiatriques d'origine chinoise atteints d'insuffisance rénale chronique (IRC). Conception: Étude qualitative et descriptive. Cadre: Le program de néphrologie de l'Hospital for Sick Children de Toronto (Canada). Sujets: Des adultes proches aidants de patients Canadiens d'origine chinoise atteints d'IRC et parlant anglais, cantonais ou mandarin. Méthodologie: Des entrevues individuelles semi-structurées ont été menées en mode virtuel par un membre de l'équipe de recherche; les entrevues ont été enregistrées (audio) et transcrites textuellement. L'analyze thématique a été utilisée pour explorer l'expérience commune des participants. Résultats: Sept entrevues ont été menées auprès des parents (6 mères et un père) de 6 patients pédiatriques Canadiens d'origine chinoise atteints d'IRC: quatre avaient subi une greffe rénale, les deux autres n'étaient pas encore inscrits sur la liste pour une transplantation. L'analyze des données a révélé que les influences culturelles affectaient la façon dont les parents parlent de la maladie et de l'expérience de leur enfant avec d'autres personnes. La conception d'origine culturelle selon laquelle il n'est pas approprié d'accabler les autres a contribué à créer de l'isolement chez les participants. Les influences culturelles ont également interféré dans le fait de demander ou non à d'autres personnes d'être donneurs vivants; les participants ont expliqué que le don vivant imposait un fardeau physique au donneur vivant (p. ex., un risque pour sa santé) et un fardeau émotionnel au participant, car ceux-ci seraient redevables au donneur consentant. La décision des parents de choisir la TRDD ou la TRDV pour leur enfant aura finalement été le résultat d'une évaluation minutieuse des deux options, avec la perspective que le choix de traitement idéal reflétait ce qui était le mieux pour tous les membres de la famille. Limites: Ces résultats reflètent les expériences d'un faible échantillon de sujets provenant d'un seul centre, ce qui peut limiter la transférabilité. Conclusion: Les parents interrogés pour cette étude estimaient avoir eu accès aux informations factuelles nécessaires pour prendre une décision éclairée dans leur choix entre la TRDD et la TRDV pour leur enfant. Les récits des participants ont décrit leur sentiment d'isolement au sein des communautés culturelles de la famille et des amis; la suggestion des participants de bénéficier d'un soutien accru pourrait guider les orientations futures de la recherche. Les praticiens peuvent offrir un soutien direct et indirect aux familles en reconnaissant l'importance des valeurs culturelles et des soins centrés sur la famille dans la prise de décisions par les familles. Il est nécessaire de créer des plateformes de soutien social virtuelles et accessibles, afin que les parents aient le sentiment de bénéficier davantage du soutien culturel d'autres parents qui partagent des expériences similaires.

Clinical relevance of HLA-DQ eplet mismatch and maintenance immunosuppression with risk of allosensitization after kidney transplant failure.

The optimal immunosuppression management in patients with a failed kidney transplant remains uncertain. This study analyzed the association of class II HLA eplet mismatches and maintenance immunosuppression with allosensitization after graft failure in a well characterized cohort of 21 patients who failed a first kidney transplant. A clinically meaningful increase in cPRA in this study was defined as the cPRA that resulted in 50% reduction in the compatible donor pool measured from the time of transplant failure until the time of repeat transplantation, death, or end of study. The median cPRA at the time of failure was 12.13% (interquartile ranges = 0.00%, 83.72%) which increased to 62.76% (IQR = 4.34%, 99.18%) during the median follow-up of 27 (IQR = 18, 39) months. High HLA-DQ eplet mismatches were significantly associated with an increased risk of developing a clinically meaningful increase in cPRA (p = 0.02) and de novo DQ donor-specific antibody against the failed allograft (p = 0.02). We did not observe these associations in patients with high HLA-DR eplet mismatches. Most of the patients (88%) with a clinically meaningful increase in cPRA had both a high DQ eplet mismatch and a reduction in their immunosuppression, suggesting the association is modified by immunosuppression. The findings suggest HLA-DQ eplet mismatch analysis may serve as a useful tool to guide future clinical studies and trials which assess the management of immunosuppression in transplant failure patients who are repeat transplant candidates.

High-Functioning Deceased Donor Kidney Transplant System Characteristics: The British Columbia Experience With an Opt-In System.

Rationale & Objective: A high level of cooperation between organ procurement organizations and transplant programs may help maximize use of deceased donor kidneys. The practices that are essential for a high functioning organ donation and transplant system remain uncertain. We sought to report metrics of organ donation and transplant performance in British Columbia, Canada, and to assess the association of specific policies and practices that contribute to the system's performance. Study Design: A retrospective observational study. Setting & Participants: Referred deceased organ donors in British Columbia were used in the study from January 1, 2016, to December 31 2019. Exposures: Provincial, organ procurement organization, and center level policies were implemented to improve donor referral and organ utilization. Outcomes: Assessment of donor and kidney utilization along steps of the critical pathway for organ donation. Analytical Approach: Deceased donors were classified according to the critical pathway for organ donation and key donation and transplant metrics were identified. Results: There were 1,948 possible donors referred. Of 1,948, 754 (39%) were potential donors. Of 754 potential donors, 587 (78%) were consented donors. Of 587 consented donors, 480 (82%) were eligible kidney donors. Of 480 eligible kidney donors, 438 (91%) were actual kidney donors. And of 438 actual kidney donors, 432 (99%) were utilized kidney donors. One-year all-cause allograft survival was 95%. Practices implemented to improve the system's performance included hospital donor coordinators, early communication between the organ procurement organization and transplant nephrologists, dedicated organ recovery and implant surgeons, aged-based kidney allocation, and hospital admission of recipients before kidney recovery. Limitations: Assignment of causality between individual policies and practices and organ donation and utilization is limited in this observational study. Conclusions: In British Columbia, consent for donation, utilization of donated kidneys, and transplant survival are exceptionally high, suggesting the importance of an integrated deceased donor and kidney transplant service.

Optimization of all possible opportunities for deceased donor kidney donation and transplantation is essential to meet the need for transplantation. We examined the performance of organ procurement and transplant in a deceased organ donor system in British Columbia, Canada, and reviewed policies and practices that may contribute to the system's performance. We found a high level of donation, transplantation, and survival of donated kidneys and identified policies and practices that likely contribute to the system's performance.

Navigating Living Kidney Donation and Transplantation Among South Asian Canadians: The ACTION Project.

RATIONALE & OBJECTIVE: South Asian (SA) Canadians with kidney failure have a 50%-77% lower likelihood of kidney transplant and are less likely to identify potential living donors (LDs). This study aimed to identify health system-, patient-, and community-level barriers and facilitators for accessing LD kidney transplantation in the SA community to inform the development of health system- and community-level interventions to address barriers. STUDY DESIGN: Qualitative study. SETTING & PARTICIPANTS: 20 SA recipients of an LD or deceased-donor kidney transplant, 10 SA LDs, and 41 general SA community members. ANALYTICAL APPROACH: In-depth multilingual interviews were conducted with recipients and LDs. Gender-, language-, and age-stratified focus groups were conducted with general SA community members. Summative content analysis was used to analyze the data. RESULTS: Hesitancy in approaching potential donors, fear about the health of potential LDs, information gaps, language barriers, and challenges evaluating out-of-country donors were highlighted as significant barriers by recipients, and financial concerns and information gaps were identified by donors. Cultural barriers in the SA community were highlighted by donors, recipients, and community members as critical factors when considering donation and transplant; women and elderly SA Canadians highlighted nuanced challenges. Participants reported generally a favorable perception of their health care teams, citing SA representation in the teams as important to providing culturally and linguistically sensitive care. LIMITATIONS: Limited geographic, race, and cultural representation and reliance on virtual data collection. CONCLUSIONS: This study highlights several culturally relevant barriers to donation and transplant that are potentially modifiable through patient-, health system-, and community-focused engagement and education.

Exploring barriers to living donor kidney transplant for African, Caribbean and Black communities in the Greater Toronto Area, Ontario: a qualitative study protocol.

INTRODUCTION: Living donor (LD) kidney transplant (KT) is the best treatment option for many patients with kidney failure as it improves quality of life and survival compared with dialysis and deceased donor KT. Unfortunately, LDKT is underused, especially among groups marginalised by race and ethnicity. African, Caribbean and Black (ACB) patients are 60%-70% less likely to receive LDKT in Canada compared with white patients. Research from the USA and the UK suggests that mistrust, cultural and generational norms, access, and affordability may contribute to inequities. To date, no Canadian studies have explored the beliefs and behaviours related to LDKT in ACB communities. Research approaches that use a critical, community-based approach can help illuminate broader structural factors that may shape individual beliefs and behaviours. In this qualitative study, we will investigate barriers to accessing LDKT in ACB communities in the Greater Toronto Area, to enhance our understanding of the perspectives and experiences of ACB community members, both with and without lived experience of chronic kidney disease (CKD). METHODS AND ANALYSIS: Hospital-based and community-based recruitment strategies will be used to recruit participants for focus groups and individual interviews. Participants will include self-identified ACB individuals with and without experiences of CKD and nephrology professionals. Collaboration with ACB community partners will facilitate a community-based research approach. Data will be analysed using reflexive thematic analysis and critical race theory. Findings will be revised based on feedback from ACB community partners. ETHICS AND DISSEMINATION: This study has been approved by the University Health Network Research Ethics Board UHN REB file #15-9775. Study findings will contribute to the codevelopment of culturally safe and responsive educational materials to raise awareness about CKD and its treatments and to improve equitable access to high-quality kidney care, including LDKT, for ACB patients.

A Survey Study to Examine Willingness to Travel for Transplantation and Consider Commercial Transplantation Among a Multiethnic Cohort of Canadians.

Introduction: Travel for transplantation is the movement of organs, donors, recipients, or transplant professionals across jurisdictional borders for transplantation purposes and is considered transplant tourism if transplant commercialism is involved. Little is known about the willingness of patients at risk for transplant tourism to engage in this practice. Methods: A cross-sectional survey of patients with end-stage renal disease was conducted in Canada to determine interest in travel for transplantation and transplant tourism, characterize patients according to their willingness to consider transplant tourism, and identify factors to deter willingness to consider transplant tourism. Surveys were conducted face-to-face and in multiple languages. Results: Among the 708 patients surveyed, 418 (59%) reported a willingness to travel outside of Canada for transplantation, with 24% reporting a strong willingness. One hundred sixty-one (23%) reported a willingness to travel and purchase a kidney overseas. On multivariate analysis, male sex, younger age, and Pacific Islander ethnicity were associated with higher odds of willingness to travel for transplant, whereas male sex, annual income greater than $100,000, and Asian and Middle Eastern ethnicity were associated with higher odds of willing to travel to purchase a kidney. Willingness reduced when respondents were informed of medical risks and legal implications related to travel for transplantation. Financial and ethical considerations were less effective at reducing willingness to travel for transplantation. Conclusion: There was a high level of interest in travel for transplantation and transplant tourism. Legal consequences and education on medical risks of transplant tourism may be effective deterrent strategies.

The Benefits of Preemptive Transplantation Using High-Kidney Donor Profile Index Kidneys.

BACKGROUND: The Kidney Donor Profile Index (KDPI) is a percentile score summarizing the likelihood of allograft failure: A KDPI ≥85% is associated with shorter allograft survival, and 50% of these donated kidneys are not currently used for transplantation. Preemptive transplantation (transplantation without prior maintenance dialysis) is associated with longer allograft survival than transplantation after dialysis; however, it is unknown whether this benefit extends to high-KDPI transplants. The objective of this analysis was to determine whether the benefit of preemptive transplantation extends to recipients of transplants with a KDPI ≥85%. METHODS: This retrospective cohort study compared the post-transplant outcomes of preemptive and nonpreemptive deceased donor kidney transplants using data from the Scientific Registry of Transplant Recipients. 120,091 patients who received their first, kidney-only transplant between January 1, 2005, and December 31, 2017, were studied, including 23,211 with KDPI ≥85%. Of this cohort, 12,331 patients received a transplant preemptively. Time-to-event models for the outcomes of allograft loss from any cause, death-censored graft loss, and death with a functioning transplant were performed. RESULTS: Compared with recipients of nonpreemptive transplants with a KDPI of 0%-20% as the reference group, the risk of allograft loss from any cause in recipients of a preemptive transplant with KDPI ≥85% (hazard ratio [HR], 1.51; 95% confidence interval [CI], 1.39 to 1.64) was lower than that in recipients of nonpreemptive transplant with a KDPI ≥85% (HR, 2.39; 95% CI, 2.21 to 2.58) and similar to that of recipients of a nonpreemptive transplant with a KDPI of 51%-84% (HR, 1.61; 95% CI, 1.52 to 1.70). CONCLUSIONS: Preemptive transplantation is associated with a lower risk of allograft failure, irrespective of KDPI, and preemptive transplants with KDPI ≥85% have comparable outcomes with nonpreemptive transplants with KDPI 51%-84%.

Motivators and Barriers to Living Donor Kidney Transplant as Perceived by Past and Potential Donors.

Background: For patients with end-stage kidney disease, living donor kidney transplant is the treatment of choice due to improved patient outcomes, longer graft survival, and reduced expenses compared with other forms of renal replacement therapy. However, organ shortage remains a challenge, and living donation rates have stagnated in recent years, particularly among men. Objective: To understand the motivators and barriers for past and potential living kidney transplant donors and inform policy and practice changes that support donors in the future. Methods: Past and potential living donors in British Columbia, Canada in the preceding 2 years were surveyed. Motivators and barriers were examined in 5 categories: family pressures and domestic responsibilities, finances, the recovery process, complications, and the transplant evaluation process. Participants ranked statements in each category on a Likert-type scale. Results: A total of 138 responses were collected. In both women and men, policies that address family and domestic responsibilities and finances were most strongly identified as motivators to donate. A large proportion of women and men reported that guaranteed job security (47% women and 38% of men), paid time off (51% of women and 42% of men), reimbursement of lost wages (49% of women and 38% of men), and protections to guarantee no impact on future insurability (62% of women and 52% of men) were significant motivators to donate. Timely and efficient medical evaluation was considered to be an important motivator for donation, with 52% of men and 43% of women reporting support for a "fast-track" option for evaluation to allow for a more rapid evaluation process. Median barrier and motivator scores were similar between women and men. Conclusion: Policies to decrease financial burden, ensure job security, improve childcare support, and offer a fast-track medical evaluation may motivate potential living kidney donors, irrespective of gender.

Contexte: La transplantation rénale avec donneur vivant est le traitement de choix pour les patients atteints d'insuffisance rénale terminale, car elle améliore les résultats de santé du patient, prolonge la survie du greffon et réduit les dépenses de santé comparativement à d'autres formes de thérapie de remplacement rénal. Cependant, la pénurie d'organes demeure un défi et les taux de dons vivants, particulièrement chez les hommes, ont stagné dans les dernières années. Objectifs: Comprendre ce qui motive les donneurs vivants d'un rein passés et potentiels, et connaître les obstacles qu'ils rencontrent. Informer les changements de politiques et de pratiques pour soutenir les donneurs dans l'avenir. Méthodologie: Un sondage mené auprès de personnes enregistrées en Colombie-Britannique (Canada) comme donneurs vivants passés et potentiels au cours des deux années précédant l'étude. Les facteurs de motivation et les obstacles ont été examinés selon cinq catégories: les pressions familiales et les responsabilités domestiques, les finances, le processus de rétablissement, les complications et le processus d'évaluation de la transplantation. Les participants devaient classer des énoncés dans chaque catégorie sur une échelle de Likert. Résultats: En tout, 138 réponses ont été recueillies. L'aspect financier et les politiques traitant des responsabilités familiales et domestiques ont été les éléments les plus fortement cités comme facteurs de motivation à donner, tant chez les femmes que chez les hommes. Une grande proportion de femmes et d'hommes ont déclaré que la sécurité d'emploi (F: 47 %; H: 38 %), les congés payés (F: 51 %; H: 42 %), le remboursement des pertes de salaire (F: 49 %; H: 38 %) et les protections visant à ne garantir aucun impact sur l'assurabilité future (F: 62 %; H: 52 %) étaient d'importants facteurs de motivation à donner. Une évaluation médicale rapide et efficace a également été considérée comme un important facteur de motivation au don, 52 % des hommes et 43 % des femmes ayant déclaré être en faveur d'une option « rapide ¼ qui permettrait d'accélérer le processus d'évaluation. Les scores médians obtenus pour les défis et facteurs de motivation étaient semblables pour les femmes et les hommes. Conclusion: Les politiques visant à réduire le fardeau financier, à assurer la sécurité d'emploi, à bonifier le soutien pour la garde des enfants et à accélérer l'évaluation médicale sont susceptibles de motiver les potentiels donneurs vivants d'un rein, quel que soit leur sexe.

ABO-adjusted calculated panel reactive antibody (cPRA): A unified metric for immunologic compatibility in kidney transplantation.

Implementation of the kidney allocation system in 2014 greatly reduced access disparity due to human leukocyte antigen (HLA) sensitization. To address persistent disparity related to candidate ABO blood groups, herein we propose a novel metric termed "ABO-adjusted cPRA," which simultaneously considers the impact of candidate HLA and ABO sensitization on the same scale. An ethnic-weighted ABO-adjusted cPRA value was computed for 190 467 candidates on the kidney waitlist by combining candidate's conventional HLA cPRA with the remaining fraction of HLA-compatible donors that are ABO-incompatible. Consideration of ABO sensitization resulted in higher ABO-adjusted cPRA relative to conventional cPRA by HLA alone, except for AB candidates since they are not ABO-sensitized. Within cPRA Point Group = 99%, 43% of the candidates moved up to ABO-adjusted cPRA Point Group = 100%, though this proportion varied substantially by candidate blood group. Nearly all O and most B candidates would have elevated ABO-adjusted cPRA values above this policy threshold for allocation priority, but relatively few A candidates displayed this shift. Overall, ABO-adjusted cPRA more accurately measures the proportion of immune-compatible donors compared with conventional HLA cPRA, especially for highly sensitized candidates. Implementation of this novel metric could enable the development of allocation policies permitting more ABO-compatible transplants without compromising equity.

Transplantation of Patients With Long Dialysis Vintage in the Current Deceased Donor Kidney Allocation System (KAS).

RATIONALE & OBJECTIVE: In 2014 the wait-time calculation for deceased donor kidney transplantation in the United States was changed from the date of first waitlisting to the date of first maintenance dialysis treatment with the aim of minimizing disparities in access to transplantation. This study examined the impact of this policy on access to transplantation, patient survival, and transplant outcomes among patients treated with maintenance dialysis for a prolonged duration before waitlisting. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: Patients identified in the US Renal Data System between 2008 and 2018 aged 18-70 years and in the 95th percentile of dialysis treatment duration (≥6.5 years) before waitlisting. EXPOSURE: Waitlisting for transplantation before versus after implementation of the policy. OUTCOME: Time from date of waitlisting to deceased donor transplantation and death, and from date of transplantation to all cause graft loss. ANALYTICAL APPROACH: Univariate and multivariable time to event analyses. RESULTS: Patients waitlisted after the policy change had a higher likelihood of deceased donor transplantation (HR, 3.12 [95% CI, 2.90-3.37]) and lower risk of death (HR, 0.74 [95% CI, 0.63-0.87]). The risk of graft loss was lower in the post-kidney allocation system (KAS) cohort (HR, 0.66 [95% CI, 0.55-0.80]). The proportion of adult patients treated with dialysis ≥6.5 years who were never waitlisted for transplantation remained high (73%) and did not decrease after the policy implementation. LIMITATIONS: Cannot determine causality in this observational study. CONCLUSIONS: The policy change was associated with an increase in deceased donor transplantation and marked improvement in patient survival for patients waitlisted after long periods of dialysis treatment without decreasing the utility of available deceased donor kidney supply. The policy was not associated with increased waitlisting of this disadvantaged population.

Use and Outcomes of Induction Therapy in Well-Matched Kidney Transplant Recipients.

BACKGROUND AND OBJECTIVES: The optimal induction treatment in low-immune risk kidney transplant recipients is uncertain. We therefore investigated the use and outcomes of induction immunosuppression in a low-risk cohort of patients who were well matched with their donor at HLA-A, -B, -DR, -DQB1 on the basis of serologic typing. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Our study was an observational study of first adult kidney-only transplant recipients in the United States recorded by the Organ Procurement and Transplant Network. RESULTS: Among 2976 recipients, 57% were treated with T cell-depleting antibodies, 28% were treated with an IL-2 receptor antagonist, and 15% were treated without induction. There was no difference in allograft survival, death-censored graft survival, or death with function between patients treated with an IL-2 receptor antagonist and no induction therapy. In multivariable models, patients treated with T cell-depleting therapy had a similar risk of graft loss from any cause, including death (hazard ratio, 1.19; 95% confidence interval, 0.98 to 1.45), compared with patients treated with an IL-2 receptor antagonist or no induction. The findings were consistent in subgroup analyses of Black recipients, patients grouped by calculated panel reactive antibody, and donor source. The incidence of acute rejection at 1 year was low (≤5%) and did not vary between treatment groups. CONCLUSIONS: Use of induction therapy with T cell-depleting therapy or IL-2 receptor antagonists in first kidney transplant recipients who are well matched with their donor at the HLA-A, -B, -DR, -DQB1 gene loci is not associated with improved post-transplant outcomes.

Compatible Donor and Recipient Pairs' Perspectives on Participation in Kidney Paired Donation Programs: A Mixed-Methods Study.

BACKGROUND: Compatible pair participation in kidney paired donation (KPD) may increase the likelihood of finding suitable matches for all registered pairs. Retrospective studies have shown variable enthusiasm for participating in KPD in compatible pairs. OBJECTIVE: The study objective was to gather potential living donor (PLD) and transplant candidate (TC) perspectives on compatible pair participation in KPD. DESIGN: Surveys and qualitative interviews. SETTING: Three transplant programs in Canada: Centre hospitalier de l'Université de Montréal in Montreal (Québec), Vancouver General Hospital, and St. Paul's Hospital in Vancouver (British Columbia). PATIENTS: Both PLDs and TCs undergoing evaluation for donation/transplantation between 2016 and 2018 at 3 transplant programs in Canada. METHODS: Descriptive statistical analysis was performed for the results of the survey and thematic and content analysis method was used for the content of the qualitative interviews. RESULTS: A total of 116 PLDs and 111 TCs completed surveys and an additional 18 PLDs and 17 TCs underwent semi-directed interviews. Of those surveyed, 61.2% of PLDs and 76.6% of TCs reported a willingness to participate in KPD as a compatible pair. The possibility of a more optimally matched kidney for the TC and policies ensuring prioritization of the TC for repeat transplantation in the event of early graft failure increased willingness to participate in KPD. Major concerns expressed during the interviews included the desire to retain the emotional bond of directed donation, the fear of chain breaks or donor reneging, delays in transplantation, and additional travel associated with participation in KPD. LIMITATION: The limitations of this study are that it was conducted in only 3 Canadian transplant programs and that the interviews and surveys were in French and in English. As a consequence, the results may not be reflective of the views of individuals not living in these 2 provinces and from ethnic minority populations. CONCLUSION: Most of the compatible PLDs and TCs surveyed were willing to participate in KPD. Ensuring timely transplantation and a more optimal match for TCs and offering a policy of reciprocity to ensure timely repeat transplantation for compatible recipients if their allograft fails post KPD transplant may further increase compatible pair participation in KPD.

CONTEXTE: La participation de paires d'individus compatibles au don croisé d'un rein (DCR) peut augmenter la probabilité de trouver des donneurs et receveurs compatibles pour tous les individus enregistrés. Des études rétrospectives ont montré un enthousiasme variable des paires d'individus compatibles à participer au DCR. OBJECTIFS: Cette étude visait à recueillir les points de vue de donneurs vivants potentiels et de candidats à la greffe sur la participation de paires d'individus compatibles au DCR. TYPE D'ÉTUDE: Sondages et interviews qualitatives. CADRE: Trois programmes de transplantation canadiens : le centre hospitalier de l'Université de Montréal à Montréal (Québec), de même que le Vancouver General Hospital et le St Paul's Hospital de Vancouver (Colombie-Britannique). SUJETS: Les donneurs vivants potentiels (DVP) et les candidats à la greffe (CG) ayant fait l'objet d'une évaluation pour un don ou une transplantation dans trois programmes de transplantation canadiens entre 2016 et 2018. MÉTHODOLOGIE: Une méthode d'analyse statistique descriptive a servi à analyser les résultats du sondage, tandis que le contenu des interviews qualitatives a été analysé à l'aide de méthodes d'analyse thématique et de contenu. RÉSULTATS: En tout, 116 DVP et 111 CG ont répondu au sondage, alors que 18 DVP et 17 CG supplémentaires ont été rencontrés pour des entrevues semi-dirigées. Parmi les répondants au sondage, 61,2 % des DVP et 76,6 % des CG ont indiqué qu'ils seraient prêts à participer au DCR en tant que membre d'une paire d'individus compatibles. La possibilité pour le CG d'obtenir un rein avec un meilleur match et les politiques assurant la priorisation du CG pour une transplantation répétée en cas d'échec précoce de la greffe ont augmenté la volonté de participer au DCR. Parmi les principales préoccupations exprimées au cours des entrevues figuraient notamment le désir de préserver le lien émotionnel du don dirigé, la peur d'une rupture dans la chaîne, la peur du renoncement du donneur, les possibles retards pour la transplantation et les déplacements supplémentaires associés à une participation au DCR. LIMITES: L'étude est limitée par le fait qu'elle n'a été réalisée que dans trois programmes canadiens de transplantation et que les entrevues et les sondages n'étaient menés qu'en français et en anglais. Les résultats pourraient par conséquent ne pas refléter les opinions des personnes issues des minorités ethniques ou ne résidant pas dans ces deux provinces. CONCLUSION: La majorité des DVP et des CG compatibles qui ont été interrogés étaient ouverts à participer au don croisé d'un rein. Il est possible d'augmenter la participation de paires d'individus compatibles au don croisé d'un rein. Pour ce faire, on doit assurer une par un meilleur match optimale et une greffe en temps opportun pour les candidats à la transplantation; il faut également offrir une politique de réciprocité assurant une greffe répétée en temps opportun aux receveurs compatibles dont l'allogreffe échoue après un DCR.

Functional joint models for chronic kidney disease in kidney transplant recipients.

This functional joint model paper is motivated by a chronic kidney disease study post kidney transplantation. The available kidney organ is a scarce resource because millions of end-stage renal patients are on the waiting list for kidney transplantation. The life of the transplanted kidney can be extended if the progression of the chronic kidney disease stage can be slowed, and so a major research question is how to extend the transplanted kidney life to maximize the usage of the scarce organ resource. The glomerular filtration rate is the best test to monitor the progression of the kidney function, and it is a continuous longitudinal outcome with repeated measures. The patient's survival status is characterized by time-to-event outcomes including kidney transplant failure, death with kidney function, and death without kidney function. Few studies have been carried out to simultaneously investigate these multiple clinical outcomes in chronic kidney disease stage patients based on a joint model. Therefore, this paper proposes a new functional joint model from this clinical chronic kidney disease study. The proposed joint models include a longitudinal sub-model with a flexible basis function for subject-level trajectories and a competing-risks sub-model for multiple time-to event outcomes. The different association structures can be accomplished through a time-dependent function of shared random effects from the longitudinal process or the whole longitudinal history in the competing-risks sub-model. The proposed joint model that utilizes basis function and competing-risks sub-model is an extension of the standard linear joint models. The application results from the proposed joint model can supply some useful clinical references for chronic kidney disease study post kidney transplantation.

Barriers to Accessing Kidney Transplantation Among Populations Marginalized by Race and Ethnicity in Canada: A Scoping Review Part 2-East Asian, South Asian, and African, Caribbean, and Black Canadians.

BACKGROUND: Kidney transplantation (KT), a treatment option for end-stage kidney disease (ESKD), is associated with longer survival and improved quality of life compared with dialysis. Inequities in access to KT, and specifically, living donor kidney transplantation (LDKT), have been documented in Canada, along various demographic dimensions. In this article, we review existing evidence about inequitable access to KT and LDKT for patients from communities marginalized by race and ethnicity in Canada. OBJECTIVE: To characterize the currently published data on rates of KT and LDKT among East Asian, South Asian, and African, Caribbean, and Black (ACB) Canadian communities and to answer the research question, "what factors may influence inequitable access to KT among East Asian, South Asian, and ACB Canadian communities?." ELIGIBILITY CRITERIA: Databases and gray literature were searched in June and November 2020 for full-text original research articles or gray literature resources addressing KT access or barriers in East Asian, South Asian, and ACB Canadian communities. A total of 25 articles were analyzed thematically. SOURCES OF EVIDENCE: Gray literature and CINAHL, OVID Medline, OVID Embase, and Cochrane databases. CHARTING METHODS: Literature characteristics were recorded and findings which described rates of and factors that influence access to KT were summarized in a narrative account. Key themes were subsequently identified and synthesized thematically in the review. RESULTS: East Asian, South Asian, and ACB communities in Canada face barriers in accessing culturally appropriate medical knowledge and care and experience inequitable access to KT. Potential barriers include gaps in knowledge about ESKD and KT, religious and spiritual concerns, stigma of ESKD and KT, health beliefs, social determinants of health, and experiences of systemic racism in health care. LIMITATIONS: This review included literature that used various methodologies and did not assess study quality. Data on ethnicity and race were not reported or defined in a standardized manner. The communities examined in this review are not homogeneous and views on organ donation and KT vary by individual. CONCLUSIONS: Our review has identified potential barriers for communities marginalized by race and ethnicity in accessing KT and LDKT. Further research is urgently needed to better understand the barriers and support needs of these communities, and to develop strategies to improve equitable access to LDKT for the growingly diverse population in Canada.

CONTEXTE: La transplantation rénale (TR), une des options de traitement de l'insuffisance rénale terminale (IRT), est associée à une meilleure qualité de vie et à une prolongation de la survie comparativement à la dialyse. Au Canada, les inégalités dans l'accès à la transplantation et plus particulièrement à la transplantation d'un rein provenant d'un donneur vivant (TRDV) ont été documentées selon diverses dimensions démographiques. Cet article fait état des données existantes sur les inégalités d'accès à la TR et à la TRDV des Canadiens issus de communautés marginalisées en raison de la race et de l'ethnicité. OBJECTIFS: L'objectif est bipartite: 1) caractériser les données publiées sur les taux de TR et de TRDV parmi les Canadiens des communautés noires originaires d'Afrique et des Caraïbes (NAC) et les Canadiens originaires de l'Asie de l'Est et de l'Asie du Sud; 2) répondre à la question de recherche « Quels facteurs pourraient mener à un accès inéquitable à la TR pour les Canadiens des communautés NAC et des communautés est-asiatiques et sud-asiatiques? ¼. CRITÈRES D'ADMISSIBILITÉ: Les bases de données et la littérature grise ont été passées en revue en juin et novembre 2020 à la recherche d'articles de recherche originaux (texte intégral) ou de ressources de la littérature grise traitant de l'accès à la TR ou des obstacles rencontrés par les Canadiens des communautés NAC et des communautés est-asiatiques et sud-asiatiques. En tout, 25 articles ont été analysés de façon thématique. SOURCES: La littérature grise et les bases de données CINAHL, OVID Medline, OVID Embase et Cochrane. MÉTHODOLOGIE: Les caractéristiques tirées de la littérature ont été consignées et les conclusions décrivant les taux de TR et les facteurs influençant l'accès ont été résumées sous forme de compte rendu. Les principaux thèmes ont été dégagés puis synthétisés thématiquement. RÉSULTATS: Les Canadiens des communautés NAC, est-asiatiques et sud-asiatiques se heurtent à divers obstacles dans l'accès à des informations et des soins médicaux adaptés à leur culture, ce qui entraîne un accès inéquitable à la TR. Le manque de connaissances concernant l'IRT et la TR, les préoccupations religieuses et spirituelles, la stigmatisation de l'IRT et de la TR, les croyances en matière de santé, les déterminants sociaux de la santé et les expériences de racisme systémique dans les soins de santé figurent parmi les possibles obstacles rencontrés. LIMITES: Cette revue inclut de la documentation dont la méthodologie varie, et la qualité des études retenues n'a pas été évaluée. Les données sur la race et l'ethnicité n'étaient pas consignées ou définies de façon normalisée. Les communautés examinées ne sont pas homogènes, les avis individuels sur le don d'organes et la TR pourraient varier. CONCLUSION: Cet examen de la portée a permis de cerner les obstacles dans l'accès à la TR et à la TRDV rencontrés par les patients des communautés marginalisées en raison de la race et de l'ethnicité. Il est urgent de poursuivre la recherche afin de mieux comprendre les obstacles et les besoins de soutien de ces communautés et pour élaborer des stratégies qui permettront un accès plus équitable à la TRDV à la population de plus en plus diversifiée du Canada.

Barriers to Accessing Kidney Transplantation Among Populations Marginalized by Race and Ethnicity in Canada: A Scoping Review Part 1-Indigenous Communities in Canada.

BACKGROUND: Kidney transplantation (KT), a treatment option for end-stage kidney disease (ESKD), is associated with longer survival and improved quality of life compared with dialysis. Inequities in access to KT, and specifically, living donor kidney transplantation (LDKT), have been documented in Canada along various demographic dimensions. In this article, we review existing evidence about inequitable access and barriers to KT and LDKT for patients from Indigenous communities in Canada. OBJECTIVE: To characterize the current state of literature on access to KT and LDKT among Indigenous communities in Canada and to answer the research question, "what factors may influence inequitable access to KT among Indigenous communities in Canada." ELIGIBILITY CRITERIA: Databases and gray literature were searched in June and November 2020 for full-text original research articles or gray literature resources addressing KT access or barriers in Indigenous communities in Canada. A total of 26 articles were analyzed thematically. SOURCES OF EVIDENCE: Gray literature and CINAHL, OVID Medline, OVID Embase, and Cochrane databases. CHARTING METHODS: Literature characteristics were recorded and findings which described rates of and factors that influence access to KT were summarized in a narrative account. Key themes were subsequently identified and synthesized thematically in the review. RESULTS: Indigenous communities in Canada experience various barriers in accessing culturally safe medical information and care, resulting in inequitable access to KT. Barriers include insufficient incorporation of Indigenous ways of knowing and being in information dissemination and care for ESKD and KT, spiritual concerns, health beliefs, logistical hurdles to accessing care, and systemic mistrust resulting from colonialism and systemic racism. LIMITATIONS: This review included studies that used various methodologies and did not assess study quality. Data on Indigenous status were not reported or defined in a standardized manner. Indigenous communities are not homogeneous and views on organ donation and KT vary by individual. CONCLUSIONS: Our scoping review has identified potential barriers that Indigenous communities may face in accessing KT and LDKT. Further research is urgently needed to better understand barriers and support needs and to develop strategies to improve equitable access to KT and LDKT for Indigenous populations in Canada.

CONTEXTE: La transplantation rénale (TR), une des options de traitement de l'insuffisance rénale terminale (IRT), est associée à une meilleure qualité de vie et à une prolongation de la survie comparativement à la dialyse. Au Canada, les inégalités dans l'accès à la transplantation et plus particulièrement à la transplantation d'un rein provenant d'un donneur vivant (TRDV) ont été documentées selon diverses dimensions démographiques. Cet article fait état des données existantes sur les inégalités d'accès à la TR et à la TRDV des patients canadiens d'origine autochtone. OBJECTIFS: Caractériser les données publiées sur les taux de TR et de TRDV chez les Canadiens d'origine autochtone et répondre à la question de recherche « Quels facteurs pourraient mener à un accès inéquitable à la TR pour les autochtones du Canada? ¼. CRITÈRES D'ADMISSIBILITÉ: Les bases de données et la littérature grise ont été passées en revue en juin et novembre 2020 à la recherche d'articles de recherche originaux (texte intégral) ou de ressources de la littérature grise traitant de l'accès à la TR ou des obstacles rencontrés par les autochtones au Canada. En tout, 26 articles ont été analysés de façon thématique. SOURCES: La littérature grise et les bases de données CINAHL, OVID Medline, OVID Embase et Cochrane. MÉTHODOLOGIE: Les caractéristiques tirées de la littérature ont été consignées et les conclusions décrivant les taux de TR et les facteurs influençant l'accès ont été résumées sous forme de compte rendu. Les principaux thèmes ont été dégagés puis synthétisés thématiquement. RÉSULTATS: Les communautés autochtones du Canada rencontrent divers obstacles dans l'accès à des informations et des soins médicaux adaptés à leur culture, ce qui entraîne un accès inéquitable à la TR. Parmi ces obstacles, on note l'intégration insuffisante des façons d'être et de faire autochtones dans la prestation de soins et dans la diffusion d'informations sur l'IRT et la TR, des préoccupations d'ordre spirituel, des croyances en matière de santé, des obstacles logistiques dans l'accès aux soins, et une méfiance bien intégrée résultant du colonialisme et du racisme systémique. LIMITATIONS: Cette revue inclut de la documentation dont la méthodologie varie, et la qualité des études retenues n'a pas été évaluée. Les données sur le statut d'Autochtone n'étaient pas consignées ou définies de façon normalisée. Les communautés autochtones ne sont pas homogènes, les avis individuels sur le don d'organes et la TR pourraient varier. CONCLUSIONS: Cet examen de la portée a permis de cerner les obstacles dans l'accès à la TR et à la TRDV rencontrés par les patients autochtones du Canada. Il est urgent de poursuivre la recherche afin de mieux comprendre les obstacles et les besoins de soutien, et pour élaborer des stratégies visant un meilleur accès à la TRDV pour les autochtones du Canada.

Pretransplant Calculated Panel Reactive Antibody in the Absence of Donor-Specific Antibody and Kidney Allograft Survival.

BACKGROUND AND OBJECTIVES: Panel reactive antibody informs the likelihood of finding an HLA-compatible donor for transplant candidates, but has historically been associated with acute rejection and allograft survival because testing methods could not exclude the presence of concomitant donor-specific antibodies. Despite new methods to exclude donor-specific antibodies, panel reactive antibody continues to be used to determine the choice of induction and maintenance immunosuppression. The study objective was to determine the clinical relevance of panel reactive antibody in the absence of donor-specific antibodies. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Retrospective observational study of kidney allograft survival among 4058 zero HLA-A-, B-, DR-, and DQB1-mismatched transplant recipients without antibodies to donor kidney antigens encoded by these HLA gene loci. RESULTS: Among 4058 first and repeat transplant recipients, patients with calculated panel reactive antibody (cPRA) 1%-97% were not at higher risk of transplant failure, compared with patients with cPRA of 0% (death censored graft loss: hazard ratio, 1.07; 95% confidence interval, 0.82 to 1.41). Patients with cPRA ≥98% had a higher risk of graft loss from any cause including death (hazard ratio, 1.39; 95% confidence interval, 1.08 to 1.79) and death censored allograft failure (hazard ratio, 1.78; 95% confidence interval, 1.27 to 2.49). In stratified analyses, the higher risk of graft loss among patients with cPRA ≥98% was only observed among repeat, but not first, transplant recipients. In subgroup analysis, there was no association between cPRA and graft loss among living related transplant recipients. CONCLUSIONS: Calculated panel reactive antibody is poorly associated with post-transplant immune reactivity to the allograft in the absence of donor-specific antibody. PODCAST: This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2021_01_25_CJN13640820_final.mp3.

A RAND-Modified Delphi on Key Indicators to Measure the Efficiency of Living Kidney Donor Candidate Evaluations.

BACKGROUND AND OBJECTIVES: Many patients, providers, and potential living donors perceive the living kidney donor evaluation process to be lengthy and difficult to navigate. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We sought consensus on key terms and process and outcome indicators that can be used to measure how efficiently a transplant center evaluates persons interested in becoming a living kidney donor. Using a RAND-modified Delphi method, 77 participants (kidney transplant recipients or recipient candidates, living kidney donors or donor candidates, health care providers, and health care administrators) completed an online survey to define the terms and indicators. The definitions were then further refined during an in-person meeting with ten stakeholders. RESULTS: We identified 16 process indicators (e.g., average time to evaluate a donor candidate), eight outcome indicators (e.g., annual number of preemptive living kidney donor transplants), and two measures that can be considered both process and outcome indicators (e.g., average number of times a candidate visited the transplant center for the evaluation). Transplant centers wishing to implement this set of indicators will require 22 unique data elements, all of which are either readily available or easily collected prospectively. CONCLUSIONS: We identified a set of indicators through a consensus-based approach that may be used to monitor and improve the performance of a transplant center in how efficiently it evaluates persons interested in becoming a living kidney donor.

Canadian Society of Transplantation and Canadian Society of Nephrology Commentary on the 2017 KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors.

PURPOSE OF REVIEW: To review an international guideline on the evaluation and care of living kidney donors and provide a commentary on the applicability of the recommendations to the Canadian donor population. SOURCES OF INFORMATION: We reviewed the 2017 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors and compared this guideline to the Canadian 2014 Kidney Paired Donation (KPD) Protocol for Participating Donors. METHODS: A working group was formed consisting of members from the Canadian Society of Transplantation and the Canadian Society of Nephrology. Members were selected to have representation from across Canada and in various subspecialties related to living kidney donation, including nephrology, surgery, transplantation, pediatrics, and ethics. KEY FINDINGS: Many of the KDIGO Guideline recommendations align with the KPD Protocol recommendations. Canadian researchers have contributed to much of the evidence on donor evaluation and outcomes used to support the KDIGO Guideline recommendations. LIMITATIONS: Certain outcomes and risk assessment tools have yet to be validated in the Canadian donor population. IMPLICATIONS: Living kidney donors should be counseled on the risks of postdonation outcomes given recent evidence, understanding the limitations of the literature with respect to its generalizability to the Canadian donor population.

JUSTIFICATION: Examiner une directive internationale sur l'évaluation et la prise en charge des donneurs vivants d'un rein et formuler un commentaire sur l'applicabilité de ces recommandations à la population des donneurs canadiens. SOURCES: Nous avons révisé le guide des pratiques cliniques relatives à l'évaluation et à la prise en charge des donneurs vivants d'un rein (Clinical Practice Guideline for Evaluation and Care of Living Kidney Donors) de 2017 du KDIGO (Kidney Disease: Improving Global Outcomes) et nous l'avons comparé aux recommandations canadiennes de 2014 du Protocole de don croisé d'un rein par donneurs participants (Kidney Paired Donation Protocol for Participating Donors). MÉTHODOLOGIE: Un groupe de travail réunissant des membres de la Société canadienne de transplantation et de la Société canadienne de néphrologie a été formé. Les membres ont été sélectionnés pour représenter tout le Canada et plusieurs sous-spécialisations relatives au don vivant d'un rein, notamment la néphrologie, la chirurgie, la transplantation, la pédiatrie et l'éthique. PRINCIPALES CONSTATATIONS: Plusieurs des recommandations du KDIGO s'harmonisent aux recommandations du protocole de don croisé d'un rein. Les chercheurs canadiens ont contribué en grande partie aux données sur l'évaluation des donneurs et des résultats utilisées pour appuyer les recommandations formulées dans les lignes directrices du KDIGO. LIMITES: Certains résultats et outils d'évaluation des risques doivent encore être validés dans la population des donneurs canadiens. CONCLUSION: Compte tenu des plus récentes données, les donneurs vivants d'un rein devraient être mis en garde concernant les risques sur leur santé post-don, tout en comprenant les limites de la littérature en ce qui concerne leur généralisabilité à la population de donneurs canadiens.