Patient Activation: The Cornerstone of Effective Self-Management in Chronic Kidney Disease?

The importance of patient activation (i.e., the knowledge, skills, and confidence one has in managing one's own healthcare) in people with long-term conditions, including kidney disease, is growing. Enabling and empowering patients to take a more active role in their health and healthcare is the focus of person-centred care. Patient activation is recognised as a key construct of self-management, as to effectively self-manage a long-term condition, it is required to enable individuals to actively participate in treatment decisions, prevent complications, and manage risk factors. Identifying an individual's level of activation can help guide and tailor care, and interventions aimed at increasing patient activation may improve patient engagement and health outcomes. In this review, we explore the concepts of patient activation and self-management, the relationship between patient activation and self-management, interventions aimed at improving these, and what these mean to people living with kidney disease.

Kidneys from patients with small renal tumours: a novel source of kidneys for transplantation.

OBJECTIVE: To report the use of a novel donor source as a further option to increase the number of patients who might be able to receive a renal transplant. PATIENTS AND METHODS: Between May 1996 and July 2007, 43 kidneys were transplanted using kidneys obtained from patients with small (<3 cm diameter) incidentally detected tumours. After bench surgery to excise the tumour, they were all successfully transplanted into patients who were elderly or had significant comorbidities. RESULTS: Apart from four patients who died from unrelated illnesses, all grafts continued to function with a median and mean follow-up of 25 and 32 months. The follow-up, which included 3-monthly renal ultrasonography and chest X-rays, showed only one case of tumour recurrence, which occurred 9 years after transplantation; the patient remains stable under observation after 18 months. CONCLUSIONS: From our experience we consider that where nephrectomy is used for small, localized, incidentally detected renal tumours, the kidney should be considered for transplantation into carefully selected patients. Such patients with numerous medical comorbidities might benefit from renal transplantation, but not survive the waiting period if they are dependent on a deceased donor graft. Paradoxically the use of these marginal kidneys has the potential to increase the quality and length of life of these patients, despite the apparent contradiction of an intuitive principle of organ transplantation and immunosuppression.

Change in live donor characteristics over the last 25 years: a single centre experience.

AIM: While deceased donor kidney transplantation rates have remained stagnant, live donor kidney transplantation (LDKT) rates have increased significantly over the last decade, and are now a major component of renal transplantation programmes worldwide. Additionally, there has been an increased utilization of more marginal donors, including donors who are obese, older and subjects with well-controlled hypertension. METHOD: A retrospective audit of all live donors at the Princess Alexandra Hospital Renal Transplantation unit was performed from 24 August 1982 to 29 May 2007 to assess any change in donor characteristics over time. RESULTS: There were 373 live donor operations. Over the last 25 years there has been a significant increase in the number of donors who are either older or obese. Furthermore, there is a greater proportion of spousal and emotionally related LDKT. CONCLUSION: It is imperative that donors, in particular marginal donors, are followed up long-term to determine their risk of kidney and cardiovascular disease and initiation of appropriate treatment if required.

Frequency and severity of acute rejection in live- versus cadaveric-donor renal transplants.

BACKGROUND: Live donors are an increasingly important source of kidneys for transplantation in Australia. The aim of this study was to compare the rate and severity of rejection between patients receiving kidney transplants from live versus cadaveric donors. METHODS: A retrospective analysis was undertaken of all patients receiving live-donor (n=109) and cadaveric-donor (n=389) renal transplants at our institution between April 1, 1994, and March 31, 2000. Follow-up was completed on all patients until graft loss, death, or May 31, 2001. RESULTS: The baseline characteristics of the live-donor and cadaveric groups were similar, except for recipient age (mean+/-SD, 36.3+/-15.6 vs. 44.5+/-14.4 years, respectively; P<0.001); donor age (46.1+/-11.3 vs. 36.1+/-16.4 years, P<0.001); pretransplant dialysis duration (1.36+/-2.1 vs. 3.4+/-4.4 years, P<0.001); and the proportions of patients receiving first allografts (95% vs. 88%, respectively; P<0.05), antibody induction (8% vs. 20%, P<0.01), and mycophenolate mofetil (MMF) (60% vs. 37%, P<0.001). Acute rejection was observed in 48 (44%) live-donor and 108 (28%) cadaveric transplants (P=0.001). Cadaveric donor type was independently predictive of less acute rejection both on logistic regression (adjusted odds ratio [AOR], 0.47; 95% confidence interval [CI], 0.30-0.73; P=0.001) and multivariate Cox proportional hazards model analysis (hazard ratio, 0.49; 95% CI, 0.34-0.69; P<0.001). Patients receiving cadaveric-donor transplants were also significantly less likely to receive antibody therapy for rejection (univariate, 18% vs. 9%; P=0.006; multivariate AOR, 0.45; 95% CI, -0.25-0.82; P<0.01), independent of recipient age, gender, race, transplant number, human leukocyte antigen mismatch, sensitization, induction therapy, delayed graft function, MMF use, tacrolimus or cyclosporine A use, sirolimus-everolimus use, year of transplant, donor age, or dialysis duration. However, donor type did not independently influence graft survival, immunologic graft survival, or patient survival. CONCLUSIONS: Live-donor kidney transplant recipients had a higher rate and severity of rejection and a shorter rejection-free period than cadaveric renal transplant recipients. Further consideration of the reasons for this difference and the use of alternative immunosuppressive strategies for live-donor transplants are recommended.

Is mycophenolate mofetil less safe than azathioprine in elderly renal transplant recipients?

BACKGROUND: Mycophenolate mofetil (MMF) is a potent immunosuppressive agent that has been shown to be superior to azathioprine in preventing early acute rejection in the general renal transplant population. However, it is uncertain whether these benefits also apply to older renal transplant recipients, who are known to be more susceptible to infectious complications and have considerably lower rates of rejection and immunological graft loss. METHODS: A retrospective analysis was undertaken of all elderly (> or =55 years old) renal transplant recipients who underwent renal transplantation at the Princess Alexandra Hospital (1994-2000) and received either MMF (n=60) or azathioprine (n=55) in combination with prednisolone and cyclosporin. Data were analyzed on an intention-to-treat basis using a multivariate Cox proportional hazards model. RESULTS: The azathioprine- and MMF-treated groups were well matched at baseline with respect to demographic characteristics, end-stage renal failure causes and transplant characteristics. Compared with the MMF cohort, azathioprine-treated patients experienced a shorter time to first rejection [hazard ratio (HR) 4.47, 95% CI 1.53-13.1, P<0.01]. However, azathioprine-treated patients were also less likely to develop opportunistic infections (HR 0.11, 95% CI 0.03-0.41, P=0.001). No differences were observed between the two groups with respect to hospitalization rates, intensive care admissions, hematological complications, or posttransplant malignancies. Actuarial 2-year survival rates for the azathioprine- and MMF-treated patients were 100 and 87%, respectively (P<0.001). The principal cause of death in the MMF cohort was infection. Using a multivariate Cox regression analysis of patient survival, an adjusted hazard ratio of 0.01 (95% CI 0.001-0.08, P=0.001) was calculated in favor of azathioprine. Overall graft survival also tended to be better in patients receiving azathioprine (HR 0.27, 95% CI 0.06-1.33, P=0.11), CONCLUSIONS: In elderly renal transplant recipients, the combination of MMF, cyclosporin, and prednisolone appears to result in a worse outcome compared with the less potent combination of azathioprine, cyclosporin, and prednisolone. Future prospective studies need to specifically evaluate the risk/benefit ratios of newer, more potent immunosuppressive protocols, such as MMF-based regimens, in this important and sizeable patient subgroup.