Changes in quality of life, health status and other patient-reported outcomes following simultaneous pancreas and kidney transplantation (SPKT): a quantitative and qualitative analysis within a UK-wide programme.

We examined quality of life (QoL) and other patient-reported outcome measures (PROMs) in 95 simultaneous pancreas and kidney transplant (SPKT) recipients and 41 patients wait-listed for SPKT recruited to the UK Access to Transplantation and Transplant Outcome Measures (ATTOM) programme. Wait-listed patients transplanted within 12 months of recruitment (n = 22) were followed 12 months post-transplant and compared with those still wait-listed (n = 19) to examine pre- to post-transplant changes. Qualitative interviews with ten SPKT recipients 12 months post-transplant were analysed thematically. Cross-sectional analyses showed several better 12-month outcomes for SPKT recipients compared with those still wait-listed, a trend to better health utilities but no difference in diabetes-specific QoL or diabetes treatment satisfaction. Pre- to post-transplant, SPKT recipients showed improved treatment satisfaction, well-being, self-reported health, generic QoL and less negative impact on renal-specific QoL (ps < 0.05). Health utility values were better overall in transplant recipients and neither these nor diabetes-specific QoL changed significantly in either group. Pre-emptive transplant advantages seen in 12-month cross-sectional analyses disappeared when controlling for baseline values. Qualitative findings indicated diabetes complications, self-imposed blood glucose monitoring and dietary restrictions continued to impact QoL negatively post-transplant. Unrealistic expectations of SPKT caused some disappointment. Measuring condition-specific PROMs over time will help in demonstrating the benefits and limitations of SPKT.

Intravenous drug users who require dialysis: causes of renal failure and outcomes.

BACKGROUND: Intravenous drug use is associated with progressive kidney disease of several aetiologies. It is associated with behavioural and lifestyle characteristics that make the provision of renal replacement therapies (RRTs) challenging. We observed that patients who use intravenous drugs [people who inject drugs (PWID)] present late to renal services and struggle to engage with treatment. We describe the experience of a UK centre providing renal services to a mixed city and rural population. METHODS: A review of electronic patient records (2003-16) was performed to identify patients actively using intravenous drugs at the time of dialysis initiation. Descriptive statistics were used to describe aetiology, treatment, complications and prognosis. RESULTS: Twenty-three patients were identified; 15 had a biopsy-proven diagnosis of AA amyloidosis. The median time from presentation to dialysis initiation was 47 days [interquartile range (IQR) 8-147.5]. Hepatitis C infection, venous thromboembolism and mental health disorders were common comorbidities. Eight patients attempted peritoneal dialysis; all failed after a median of 30 days (IQR 21.75-83). One-year survival was 65% (95% confidence interval 42-80), significantly lower than 2013 UK renal registry statistics for incident haemodialysis patients <65 years of age (94.2%). CONCLUSIONS: PWID who develop end-stage kidney disease in our region predominantly have AA amyloidosis. Most present late to renal services and have poor outcomes on all forms of RRT. Rates of transplantation are low. Management challenges include coexisting alcohol and mental health problems, low socio-economic status, contamination of intravenous dialysis access and chaotic lifestyles. Multidisciplinary management with enhanced social support may be beneficial in improving outcomes for this patient group.

Health literacy and patient outcomes in chronic kidney disease: a systematic review.

Background: Limited health literacy affects 25% of people with chronic kidney disease (CKD), and may reduce self-management skills resulting in poorer clinical outcomes. By disproportionately affecting people with low socio-economic status and non-white ethnicity, limited health literacy may promote health inequity. Methods: We performed a systematic review of quantitative studies of health literacy and clinical outcomes among adults with CKD. Results: A total of 29 studies (13 articles; 16 conference abstracts) were included. One included non-USA patients. Of the 29 studies, 5 were cohort studies and 24 were cross-sectional. In all, 18 300 patients were studied: 4367 non-dialysis CKD; 13 202 dialysis; 390 transplant; 341 unspecified. Median study size was 127 [interquartile range (IQR) 92-238)], but 480 (IQR 260-2392) for cohort studies. Median proportion of non-white participants was 48% (IQR 17-70%). Six health literacy measures were used. Outcomes included patient attributes, care processes, clinical/laboratory parameters and 'hard' clinical outcomes. Limited health literacy was significantly, independently associated with hospitalizations, emergency department use, missed dialysis sessions, cardiovascular events and mortality (in cohort studies). Study quality was high (1 study), moderate (3 studies) and poor (25 studies), limited by sampling methods, variable adjustment for confounders and reduced methodological detail given in conference abstracts. Conclusions: There is limited robust evidence of the causal effects of health literacy on patient outcomes in CKD. Available evidence suggests associations with adverse clinical events, increased healthcare use and mortality. Prospective studies are required to determine the causal effects of health literacy on outcomes in CKD patients, and examine the relationships between socio-economic status, comorbidity, health literacy and CKD outcomes. Intervention development and evaluation will determine whether health literacy is a modifiable determinant of poor outcomes in CKD.

Immunosuppression in the elderly renal allograft recipient: a systematic review.

BACKGROUND: The Elderly are the fastest growing part of kidney transplant recipients. The best immunosuppressive strategy is unknown. METHODS: We performed a systematic search of randomized controlled trials and observational studies focused on safety and efficacy of different immunosuppression strategies in elderly kidney recipients. Data extraction and risk of bias evaluation were systematically performed. RESULTS: Ten studies were included: 2 randomized clinical trials and 8 observational. A marginal benefit was found for early renal function with delayed tacrolimus or complete tacrolimus avoidance using mycophenolate mofetil (MMF). Observational cohort studies looked at different antibody induction strategies, calcineurin-inhibitors based maintenance immunosuppression, calcineurin-inhibitor-free sirolimus-based therapy and use of MMF versus azathioprine. Treatment with interleukin-2 receptor antibody induction, calcineurin-inhibitor minimization with MMF and steroid minimization is advisable in the low immunologic risk elderly recipient, considering the increased risk of toxicities, infection and malignancies. In the high immunologic risk elderly recipient, taking into account the morbid consequences of acute rejection in the elderly, observational studies support antibody induction with depletive antibodies, calcineurin-inhibitor, MMF and steroids; calcineurin-inhibitor-minimization is not recommended. CONCLUSIONS: There is very limited evidence for the benefits and harms of different immunosuppression strategies in the elderly. Most of the published literature are observational studies, and randomized controlled trials are urgently needed.

Strategies to increase the donor pool and access to kidney transplantation: an international perspective.

In this position article, DESCARTES (Developing Education Science and Care for Renal Transplantation in European States) board members describe the current strategies aimed at expanding living and deceased donor kidney pools. The article focuses on the recent progress in desensitization and kidney paired exchange programmes and on the expanded criteria for the use of donor kidneys and organs from donors after circulatory death. It also highlights differences in policies and practices across different regions with special regard to European Union countries. Living donor kidney paired exchange, the deceased donor Acceptable Mismatch Programme and kidneys from donors after circulatory death are probably the most promising innovations for expanding kidney transplantation in Europe over the coming decade. To maximize success, an effort is needed to standardize transplant strategies, policies and legislation across European countries.

Guías Europeas sobre manejo y evaluación de receptores y donantes renales / European Renal Best Practice Guideline on the Management and Evaluation of the Kidney Donor and Recipient

El objetivo de esta Guía de Práctica Clínica es ofrecer orientación para la evaluación tanto del donante como del receptor del trasplante de riñón y para el manejo del receptor durante el periodo perioperatorio. Ha sido diseñada para informar y asistir en la toma de decisiones. En ningún caso pretende definir una norma asistencial ni su carácter debe concebirse como tal ni interpretarse como prescriptivo de un manejo exclusivo. La versión original de esta guía fue publicada en larevista Nephrology, Dialysis and Transplantation. Esta versión reducida pretende colaborar en la divulgación de esta guía en los países y comunidades trasplantadoras hispanohablantes (AU)

The purpose of this Clinical Practice Guideline is to provide guidance on evaluation of the kidney donor and transplant recipient as well as on the management of the recipient in the perioperative period. It is designed to provide information and aid decision-making. It is not intended to define a standard of care, and should neither be construed as one nor should it be interpreted as prescribing an exclusive course of management. The original version of this guideline was published in Nephrology, Dialysis and Transplantation and this current version is a reduced article aiming to disseminate the guideline into Spanish-speaking countries and transplant communities (AU)

European renal best practice guideline on the management and evaluation of the kidney donor and recipient.

The purpose of this Clinical Practice Guideline is to provide guidance on evaluation of the kidney donor and transplant recipient as well as on the management of the recipient in the perioperative period. It is designed to provide information and aid decision-making. It is not intended to define a standard of care, and should neither be construed as one nor should it be interpreted as prescribing an exclusive course of management. The original version of this guideline was published in Nephrology, Dialysis and Transplantation and this current version is a reduced article aiming to disseminate the guideline into Spanish-speaking countries and transplant communities.

Summary of the British Transplantation Society/Renal Association U.K. guidelines for living donor kidney transplantation.

The third edition of the joint British Transplantation Society/Renal Association guidelines for living donor kidney transplantation was published in May 2011. The guideline has been extensively revised since the previous edition in 2005 and has used the GRADE system to rate the strength of evidence and recommendations. This article summarizes the statements of recommendation contained in the guideline, which provide a framework for the delivery of living kidney donation in the United Kingdom and may be of wide international interest. It is recommended that the full guideline document is consulted for details of the relevant references and evidence base. This may be accessed at http://www.bts.org.uk/transplantation/standards-and-guidelines/ and http://www.renal.org/clinical/OtherGuidelines.aspx (transplantation is welcome to add a web link in this article to/through its own Web site to increase traffic).

Social deprivation, ethnicity, and uptake of living kidney donor transplantation in the United Kingdom.

BACKGROUND: Socioeconomic disparities and their contribution to the ethnic differences in living kidney donor transplantation have not been adequately studied. METHODS: A total of 12,282 patients aged 18 to 69 years starting renal replacement therapy (January 1, 1997, to December 31, 2004) in the United Kingdom were included. Logistic regression models were used to examine probability of living donor transplantation within 3 years of renal replacement therapy. The effect of area deprivation (Townsend index) was studied among whites only adjusted for patient characteristics and the effect of ethnic origin (South Asians and blacks compared with whites) was then examined among all patients adjusting for area deprivation. RESULTS: Among whites, increasing social deprivation was associated with lower odds of living donor transplantation. In the fully adjusted model, odds ratio (OR) for the most deprived quintile was 0.40 (95% confidence interval [CI] 0.33, 0.49; P trend<0.0001) compared with the least deprived. These gradients were more pronounced among centers performing more live donor transplants (P value for interaction <0.0001). South Asians and blacks had lower odds of living donor transplantation compared with whites, but there was an interaction with age (P<0.0001), so that this disparity was observed only in those younger than 50 years (blacks: OR, 0.31; 95% CI, 0.18, 0.54; South Asians: OR, 0.55; 95% CI, 0.34, 0.90; P value <0.0001). CONCLUSIONS: Socially deprived and younger ethnic minority patients have lower probability of living kidney donor transplantation. The extent to which these inequalities reflect modifiable societal healthcare system barriers and donor/recipient factors requires further study.

Social deprivation, ethnicity, and access to the deceased donor kidney transplant waiting list in England and Wales.

BACKGROUND: Socioeconomic and ethnic inequity in access to kidney transplant waiting list has been described in the United States but not examined in a universal healthcare system. METHODS: Eleven thousand two hundred ninety-nine patients aged 18 to 69 years starting renal replacement therapy (January 1, 1997 to December 31, 2004) in England and Wales were included. Multivariable Cox proportional hazards models were used to assess time to activation on the transplant waiting list for socially deprived patients among white patients. The effect of ethnic origin (South Asians and blacks compared with whites) was examined among all patients. RESULTS: Among white patients, in the fully adjusted model, the hazard ratio (HR) for the most deprived quintile was 0.60 (95% confidence interval [CI] 0.54-0.68, P trend <0.0001) compared with the least deprived. Deprivation effects were more pronounced among those 50 years and older (P value for interaction <0.0001). Non-whites had a lower risk of being waitlisted than whites (for blacks: HR 0.89, 95% CI 0.79-1.01; for South Asians: HR 0.91, 95% CI 0.83-0.99, P value for heterogeneity=0.03). These differences were attenuated in a fully adjusted model. However non-whites who were 50 years and older were more likely to be transplant waitlisted than whites (interaction P=0.002). CONCLUSIONS: Individuals living in socially deprived areas have reduced access to the transplant waiting list. Understanding the reasons for this apparent inequity is important if we wish to ensure equitable access to renal transplants. There were no major differences by ethnicity, and if anything, older white patients were less likely to be waitlisted.

Effects of immediate switch from cyclosporine microemulsion to tacrolimus at first acute rejection in renal allograft recipients.

BACKGROUND: A number of institutions have reported favorable results in renal transplant patients after conversion from cyclosporine (CsA) to tacrolimus at the time of acute rejection, but no prospective, controlled study has been performed to date. Here, we report the first randomized study comparing patients whose therapy was changed at a first episode of acute rejection to tacrolimus with those who were maintained on CsA microemulsion (ME). METHODS: This 3-month, prospective, open, multicenter, parallel-group study was conducted at 15 centers in seven European countries. In total, 119 renal graft recipients experiencing a first biopsy-proven acute rejection episode while receiving CsA-ME were randomized (1:1) to start tacrolimus-based therapy (n=61) or to continue CsA-ME-based therapy (n=58). RESULTS: Baseline characteristics were comparable for both groups. The initial rejection episode responded to steroid treatment in 93.4% (tacrolimus) and 63.8% (CsA-ME) (P=0.001), respectively. In patients at risk, the incidence of recurrent rejection events within 3 months was significantly lower with tacrolimus therapy (5/57, 8.8%) compared with CsA-ME therapy (15/44, 34.1%) (P=0.002). Patient and graft survival were similar in both study groups 3 months after randomization. The most frequently reported adverse events were increased serum creatinine (29.5% vs. 22.4%), hypertension (24.6% vs. 22.4%), and urinary tract infection (18.0% vs. 20.7%) for tacrolimus versus CsA-ME. Tremor was more common in tacrolimus treated-patients (17.4% vs. 2.1%, P=0.011). CONCLUSIONS: Early conversion to tacrolimus therapy benefited the resolution of acute rejection episodes and significantly reduced the risk of recurrent rejection compared with continuation of CsA-ME.