Kidney dysfunction and cognitive decline in women.

BACKGROUND AND OBJECTIVES: ESRD is associated with substantial cognitive deficits but whether earlier kidney dysfunction predicts cognitive decline is less well defined. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: More than 1700 women aged ≥70 years in the Nurses' Health Study had plasma creatinine and urinary albumin/creatinine ratios (ACRs) measured in 2000, within 12 months of their initial cognitive testing. These participants had repeated assessments of cognition administered by phone every 2 years, including tests for general cognition, verbal memory, verbal fluency, and working memory for up to 6 years of follow-up. Mixed-effects regression analysis was applied to calculate mean differences in the rate of cognitive decline between women with an estimated GFR <60 ml/min per 1.73 m(2) or an ACR ≥5 mg/g versus referent levels. RESULTS: The median age was 74 years at initial cognitive testing, 99% of women were Caucasian, median plasma creatinine was 0.8 mg/dl, and 25% had an ACR ≥5 mg/g. The difference in cognitive decline with a baseline ACR ≥5 mg/g versus an ACR <5 mg/g was equivalent to the difference observed with 2-7 years of aging; that is, a higher ACR was associated with 2-7 times faster decline in all four cognitive domains assessed (all P values <0.05) than that attributed to each 1 year of aging alone. No associations were observed between an eGFR <60 ml/min per 1.73 m(2) and cognitive decline. CONCLUSIONS: A baseline urinary ACR ≥5 mg/g, a level not traditionally considered clinically significant, is independently associated with faster decline in cognitive function.

A comparison of early versus late initiation of renal replacement therapy in critically ill patients with acute kidney injury: a systematic review and meta-analysis.

INTRODUCTION: Our aim was to investigate the impact of early versus late initiation of renal replacement therapy (RRT) on clinical outcomes in critically ill patients with acute kidney injury (AKI). METHODS: Systematic review and meta-analysis were used in this study. PUBMED, EMBASE, SCOPUS, Web of Science and Cochrane Central Registry of Controlled Clinical Trials, and other sources were searched in July 2010. Eligible studies selected were cohort and randomised trials that assessed timing of initiation of RRT in critically ill adults with AKI. RESULTS: We identified 15 unique studies (2 randomised, 4 prospective cohort, 9 retrospective cohort) out of 1,494 citations. The overall methodological quality was low. Early, compared with late therapy, was associated with a significant improvement in 28-day mortality (odds ratio (OR) 0.45; 95% confidence interval (CI), 0.28 to 0.72). There was significant heterogeneity among the 15 pooled studies (I(2) = 78%). In subgroup analyses, stratifying by patient population (surgical, n = 8 vs. mixed, n = 7) or study design (prospective, n = 10 vs. retrospective, n = 5), there was no impact on the overall summary estimate for mortality. Meta-regression controlling for illness severity (Acute Physiology And Chronic Health Evaluation II (APACHE II)), baseline creatinine and urea did not impact the overall summary estimate for mortality. Of studies reporting secondary outcomes, five studies (out of seven) reported greater renal recovery, seven (out of eight) studies showed decreased duration of RRT and five (out of six) studies showed decreased ICU length of stay in the early, compared with late, RRT group. Early RRT did not; however, significantly affect the odds of dialysis dependence beyond hospitalization (OR 0.62 0.34 to 1.13, I(2) = 69.6%). CONCLUSIONS: Earlier institution of RRT in critically ill patients with AKI may have a beneficial impact on survival. However, this conclusion is based on heterogeneous studies of variable quality and only two randomised trials. In the absence of new evidence from suitably-designed randomised trials, a definitive treatment recommendation cannot be made.

Transplantation of A2 kidneys into B and O recipients leads to reduction in waiting time: USRDS experience.

INTRODUCTION: Strategy of transplanting kidneys from A2 donors into patients with blood group B and O recipients has been used to alleviate the long waiting times. MATERIALS AND METHODS: We used an inception cohort of US Renal Data System data base with patients older than 18 years who underwent renal transplantation between January 1995 and July 2006. The primary outcome variable was allograft loss (including death). Bivariate analysis of factors associated with receiving A2 or A2B kidneys was performed with chi-square testing for categorical variables (Fisher's exact test used for violations of Cochran's assumptions) and Student's t test for continuous variables (Mann-Whitney U test used for nonnormally distributed variables). RESULTS: There were 150,118 first kidney transplants of whom 113 received kidney transplant from A2 to O, and 125 patients received A2 to B kidney transplant. Compared with other recipients from the same blood group, recipients of A2 kidneys had significantly shorter wait times. O recipients had a median wait time of 1.63 years (range 0.00-17.21 years), whereas O recipients who received A2 kidneys had a median wait time of 0.70 years (range 0.02-1.47 years; P<0.001). B recipients had a median wait time of 1.90 years (range 0.00-17.52 years), whereas B recipients who received A2 kidneys had a median wait time of 0.74 years (range 0.10-5.21 years; P<0.001). There was no significant difference in graft loss or death between A2 to O and B versus all other recipients. CONCLUSIONS: The results showed that comparatively few patients received A2 to B or O kidney transplant.

Commercialization of kidney transplants: a systematic review of outcomes in recipients and donors.

In this study we systematically reviewed outcomes in recipients and donors of commercial kidney transplants. Inherent in a study of this nature is the possibility of center and country bias, in particular there are no publications from China and South America. Publications also tended to report poor outcomes which may reflect bias on the part of the authors or to highlight the ethical issues in this area. We were unable to perform a meta-analysis due to variability in studies making it impossible to synthesize the data other than descriptive. Furthermore, these studies were not large or well conducted. We found that patient and graft survival was generally inferior to the data obtained from the UNOS (United Network for Organ Sharing). Some studies did achieve good outcomes, however, due to lack of details, it was not possible to infer if the donor hospital, surgical technique or immunosuppressive regimen was a factor. There was a higher incidence of unconventional and life-threatening infections such as malaria, invasive fungal infections, pneumonia, HIV and hepatitis. There was also a markedly increased incidence of postoperative surgical interventions in recipients. We suggest the establishment of a database for both recipients and donors to identify unique surgical, medical, infectious and immunosuppressive protocols for the recipients and donors in these hospitals. This could lead to better liaison between the recipient and donor hospitals so that modern surgical and medical practices can be implemented. There should also be improved emotional and psychological support to both the recipient and the donor. However, these steps could be seen as condoning the reprehensible practice of commercialization of human body parts.

The dynamics of recipient-donor relationships in living kidney transplantation.

Psychosocial issues in kidney transplant donors and recipients are a cause for concern. We reviewed studies that investigated psychosocial issues in donors and recipients of living kidney transplants. A variety of instruments were used for this purpose. However, there was a lack of consensus regarding the structure and method of psychosocial assessment in living kidney donors. We found that only a few centers currently carry out a systematic psychosocial follow-up of recipients and their donors. The majority of psychosocial studies were of living kidney donors, indicating a preference of researchers to study psychosocial issues in live kidney donors. We believe living kidney transplant recipients are also an important group, and more studies should be done to better understand the psychosocial issues in this group. The majority of studies were retrospective in nature. We also discuss relationships, interactions, and communication patterns that characterize living kidney donation. We place emphasis on understanding the relational history of donors and recipients to provide supportive intervention and enable the potential donor make an informed decision about surgery. We recommend comprehensive psychosocial screening before and after transplantation and donation. This may decrease psychological problems and increase satisfaction with the transplantation process. Furthermore, the transplant community will need to address the type of instruments, duration of follow-up, and funding sources to carry out our recommendations.

Kidney transplantation and gender disparity.

Gender inequity in access to hemodialysis and kidney transplantation has created a public health crisis in the US. Women have a lower chance of receiving hemodialysis and kidney transplant than men, but they constitute the majority of living kidney donors. Research has shown that economic factors such as greater income of men may encourage females to be donors; while gender-bias on part of physicians or institutions, lack of social support networks and differences in health-seeking behaviors compared to men are cited as reasons for this imbalance. We suggest various strategies to improve participation of women in the transplant process by education; raising awareness by publishing gender-specific data for dialysis and transplant centers; education and workshops to eliminate gender-bias within institutions and health-care providers and establishment of gender-specific support groups. Transplant teams that are more sensitive to the social complexities of women's lives may lead to increased understanding of the effects of renal disease and indicate measures that need to be in place in order to address this gender disparity in the treatment of renal failure. Research needs to be done to elucidate the underlying medical, societal or psychological processes that lead to gender bias in the field of kidney transplantation.