Granulocyte colony-stimulating factor with or without immunosuppression reduction in neutropenic kidney transplant recipients.

INTRODUCTION: Neutropenia post-kidney transplantation is associated with adverse graft and patient outcomes. We aimed to analyze the effect of granulocyte colony-stimulating factor (G-CSF) use with and without immunosuppression reduction on graft outcomes in neutropenic recipients. METHODS: In this retrospective cohort study, we identified 120 recipients with neutropenia, within the first-year post-transplant. RESULTS: Of these, 45.0% underwent no intervention, 17.5% had immunosuppression reduced, 18.3% were only given G-CSF, and 19.2% had both interventions. Overall, 61 patients experienced the composite outcome of de-novo DSA, biopsy-proven acute rejection, and all-cause graft failure and the cumulative incidence of this outcome did not vary by any of the four interventions (p = .93). When stratifying the cohort by G-CSF use alone, those who received G-CSF were more likely to have had severe neutropenia (<500/mm3 : 51.1% vs. 12.0%, p < .001), and immunosuppression reduction (51.1% vs. 28.0%, p = .003). However, the composite outcome was not different in the G-CSF and no G-CSF cohort (53.3% vs. 49.3%, p = .67), and in a multivariate model, G-CSF use was not associated with this outcome (aHR = 1.18, 95% CI: .61-2.30). However, a trend towards higher DSA production was noted in the G-CSF cohort (87.5% vs. 62.2%) and this observation warrants prospective evaluation. CONCLUSION: Overall, we conclude that G-CSF use with or without immunosuppression reduction was not associated with graft outcomes.

Effects of a Knowledge-Translation Intervention on Early Dialysis Initiation: A Cluster Randomized Trial.

BACKGROUND: The Initiating Dialysis Early and Late (IDEAL) trial, published in 2009, found no clinically measurable benefit with respect to risk of mortality or early complications with early dialysis initiation versus deferred dialysis start. After these findings, guidelines recommended an intent-to-defer approach to dialysis initiation, with the goal of deferring it until clinical symptoms arise. METHODS: To evaluate a four-component knowledge translation intervention aimed at promoting an intent-to-defer strategy for dialysis initiation, we conducted a cluster randomized trial in Canada between October 2014 and November 2015. We randomized 55 clinics, 27 to the intervention group and 28 to the control group. The educational intervention, using knowledge-translation tools, included telephone surveys from a knowledge-translation broker, a 1-year center-specific audit with feedback, delivery of a guidelines package, and an academic detailing visit. Participants included adults who had at least 3 months of predialysis care and who started dialysis in the first year after the intervention. The primary efficacy outcome was the proportion of patients who initiated dialysis early (at eGFR >10.5 ml/min per 1.73 m2). The secondary outcome was the proportion of patients who initiated in the acute inpatient setting. RESULTS: The analysis included 3424 patients initiating dialysis in the 1-year follow-up period. Of these, 509 of 1592 (32.0%) in the intervention arm and 605 of 1832 (33.0%) in the control arm started dialysis early. There was no difference in the proportion of individuals initiating dialysis early or in the proportion of individuals initiating dialysis as an acute inpatient. CONCLUSIONS: A multifaceted knowledge translation intervention failed to reduce the proportion of early dialysis starts in patients with CKD followed in multidisciplinary clinics. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER: ClinicalTrials.gov, NCT02183987. Available at: https://clinicaltrials.gov/ct2/show/NCT02183987.

Autosomal dominant polycystic kidney disease.

Autosomal dominant polycystic kidney disease (ADPKD) is the most common hereditary kidney disease and one of the most common causes of end-stage kidney disease. Multiple clinical manifestations, such as enlarged kidneys filled with growing cysts, hypertension, and multiple extrarenal complications, including liver cysts, intracranial aneurysms, and cardiac valvular disease, show that ADPKD is a systemic disorder. New information derived from clinical research using molecular genetics and advanced imaging techniques has provided enhanced tools for assessing the diagnosis and prognosis for individual patients and their families. Phase 3 randomised, placebo-controlled clinical trials have clarified aspects of disease management and a disease-modifying therapeutic drug is now available for patients with high risk of rapid disease progression. These developments provide a strong basis on which to make clear recommendations about the management of affected patients and families. Implementation of these advances has the potential to delay kidney failure, reduce the symptom burden, lessen the risk of cardiovascular complications, and prolong life.

External validation of prediction models for mortality in an incident dialysis population
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AIMS: Different prediction models have been established to estimate mortality in the dialysis population. This study aims to externally validate the different available mortality prediction models in an incident dialysis population. MATERIALS: This was a retrospective cohort study of incident hemodialysis and peritoneal dialysis patients at two academic tertiary care centers. METHODS: Three previously published prediction models were used: the Liu index, the Urea5 score, and a predictive model estimating the survival probability by Hemke et al. [6]. Models were compared using the C-statistic, net reclassification index, and integrated discrimination improvement. Only the subgroup of 193 patients with enough data to be included in all models was used. RESULTS: 377 patients were started on dialysis in both institutions between 2006 and 2011. Median follow-up was 787 days. 104 patients (27.6%) died during follow-up and 181 were admitted to the hospital (48.0%). All three models were predictive of mortality and hospital admissions. The survival probability model by Hemke et al. [6] performed better than the other two models for mortality (C-statistic 0.72). The Liu index had the highest performance for hospital admissions (C-statistic 0.65). Using reclassification statistics (reference = Urea5), the only model to improve discriminatory ability was the Liu index for the outcome of hospital admission. CONCLUSION: The survival probability model by Hemke et al. [6] may be preferred for mortality prediction in incident dialysis patients. The Liu index could be used to predict hospital admissions in the same population. Available models demonstrated only modest performance in predicting either outcome. Therefore, alternative models need to be developed.
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Platelet reactivity in stable cardiovascular patients with chronic kidney disease.

The study aimed to evaluate antiplatelet drug responsiveness in stable outpatients with cardiovascular disease and chronic kidney disease (CKD) and examine whether impaired antiplatelet drug responsiveness is associated with worse clinical outcomes in this population. Stable cardiovascular patients (n = 771) were enrolled at least one month after an acute ischemic atherothrombotic event. Antiplatelet drug responsiveness was assessed with specific assays (serum TxA2 for aspirin, the VASP assay for clopidogrel) and other aggregation-based assays using different agonists. All patients were followed until the first occurrence of a major adverse cardiovascular event. The 133 CKD patients were found to have higher activity of von Willebrand factor and higher fibrinogen levels. After a median follow-up of 33 months, 88 events occurred in patients without CKD and 31 events in patients with CKD (5.0 events and 8.7 events per 100 patient years, respectively, HR = 1.75 (95% CI 1.16-2.63; p = 0.008). The prevalence of poor aspirin and clopidogrel responsiveness and high platelet reactivity as assessed with different aggregation-based assays was similar in patients with estimated GFR ≥ 60 ml/min, 45-59 ml/min, and < 45 ml/min. No significant interaction for CKD vs. non-CKD was observed for events occurrence in patients with or without high platelet reactivity on several assays, with the exception of collagen-induced aggregation. In stable cardiovascular patients, CKD is not associated with higher platelet reactivity. Decreased antiplatelet drug responsiveness is not associated with worse clinical outcomes in CKD patients.

Serial versus single troponin measurements for the prediction of cardiovascular events and mortality in stable chronic haemodialysis patients.

AIM: This study aims to describe the variability of pre-dialysis troponin values in stable haemodialysis patients and compare the performance of single versus fluctuating or persistently elevated troponins in predicting a composite of mortality and cardiac arrest, myocardial infarction or stroke. METHODS: A total of 128 stable ambulatory chronic haemodialysis patients were enrolled. Pre-dialysis troponin I was measured for three consecutive months. The patients were followed for 1 year. A troponin elevation (>0.06 µg/L) was considered high risk, and patients were classified into three risk groups: (i) patients who had normal troponin levels on all three measurements; (ii) patients with at least one elevated and one normal troponin value; and (iii) patients with elevated troponin values on all measurements. RESULTS: A total of 81 patients had all three troponin values in the normal range; 29 had fluctuating values; 18 had all three values elevated. Twenty-seven deaths or composite events were observed: eight in the first risk group, 10 in the second and nine in the third. Persistently elevated and fluctuating troponin values were associated with higher mortality and cardiovascular event rate. Serial troponin measurement had a higher sensitivity for the composite outcome than single troponin measurement when either fluctuating or persistently elevated values were considered to confer high risk. CONCLUSION: Most haemodialysis patients do not have elevated troponin levels at baseline. Troponin levels that remain elevated or fluctuate are associated with worse outcomes. A serial troponin measurement strategy is associated with better sensitivity and higher negative predictive value compared with single troponin measurement.

What Is Autosomal Dominant Polycystic Kidney Disease?

This JAMA Patient Page describes autosomal dominant polycystic kidney disease, its signs and symptoms, diagnosis, and treatment options.

Impact of acute kidney injury following liver transplantation on long-term outcomes.

BACKGROUND: The incidence of acute kidney injury (AKI) after liver transplantation (LTx) ranges from 17% to 94%. AKI is associated with prolonged hospitalization and increased early mortality. In our cohort study, we examined the impact of AKI on long-term patient survival and on the incidence of stage 4-5 chronic kidney disease (CKD). METHODS: We studied 491 LTx recipients at a single center between 1990 and 2012. We identified 278 pts (56.6%) with AKI defined as either an increase in serum creatinine (SCr) ≥26.5 µmol/L within 48 hour or elevation in SCr 1.5× baseline within 7 days (KDIGO criteria). RESULTS: In a multivariable Cox proportional hazards model, survival was worse in patients with AKI (HR: 1.41, 95% CI 1.03-1.92). Severe (stage 3) AKI was associated with worse patient survival (HR: 2.29, 95% CI 1.46-3.58). The risk of developing stage 4-5 CKD was also higher in patients with AKI (17.5% vs 9.1%) with a HR of 2.39 (95% CI 1.27-4.47). Delaying initiation of calcineurin inhibitors >48H was not associated with a decreased risk of CKD. CONCLUSIONS: Our findings suggest that AKI after LTx is associated with poor long-term outcomes, including worse survival and higher incidence of CKD stage 4-5. Strategies to prevent and manage LTx patients with AKI need to be developed.

High Ultrafiltration Rates Increase Troponin Levels in Stable Hemodialysis Patients.

BACKGROUND: An elevated troponin level is commonly found in asymptomatic patients on hemodialysis (HD) and is associated with higher risk of mortality and major adverse cardiovascular events. The underlying mechanism for the association between adverse outcomes and elevated troponin levels has not been elucidated. METHODS: Two hundred thirty-six stable chronic HD patients from 2 tertiary care centers were enrolled in this study. We measured pre-dialysis troponin I levels with routine monthly bloods for 3 consecutive months. Troponin I was considered to be elevated if it exceeded the laboratory reference range of 0.06 µg/l. RESULTS: The study population had a mean age of 67.5, 56% were male, 47% had diabetes and 28% had pre-existing coronary artery disease. Eighty-eight positive troponin values were recorded (13% of the available values) in 52 patients. In a repeated measures linear random effects model (univariate analysis), high ultrafiltration (UF), high inter-dialytic weight gain, and duration of the dialysis session, but not intra-dialytic hypotension, were associated with troponin I elevation. In the multivariate model, only high UF explained troponin I elevation (p = 0.04). The intraclass correlation coefficient was found to be 5.8%, suggesting that observed variability is within and not between subjects, with session-related parameters being more important than inter-individual differences. CONCLUSIONS: A high UF rate during HD is associated with a biochemical evidence of myocardial injury. If confirmed, efforts to avoid rapid UF, protect residual kidney function or minimize weight gain between sessions may impact cardiovascular outcomes in this high-risk population.

Risk factors for progression in ADPKD.

PURPOSE OF REVIEW: Autosomal dominant polycystic kidney disease (ADPKD) is the most common hereditary kidney disease. This article will describe the factors associated with both functional and structural evidence of disease progression. It will also review the results of recent clinical trials that have shown an impact on markers of disease progression. RECENT FINDINGS: A variety of prognostic factors have been described that relate to a decline in glomerular filtration rate or an increase in total cyst or kidney volumes. We now have clinical trials that show that glomerular filtration rate decline and kidney volume growth can be slowed in those with ADPKD. SUMMARY: With the emergence of potential disease-modifying therapies, factors that can accurately identify those who are most at risk for renal progression or ADPKD-related complications need to be identified and validated.

Total Kidney Volume in Autosomal Dominant Polycystic Kidney Disease: A Biomarker of Disease Progression and Therapeutic Efficacy.

Autosomal dominant polycystic kidney disease (ADPKD) is the most common potentially life-threatening monogenic disorder in humans, characterized by progressive development and expansion of fluid-filled cysts in the kidneys and other organs. Ongoing cyst growth leads to progressive kidney enlargement, whereas kidney function remains stable for decades as a result of hyperfiltration and compensation by unaffected nephrons. Kidney function irreversibly declines only in the late stages of the disease, when most of the parenchyma is lost to cystic and fibrotic tissue and the remaining compensatory capacity is overwhelmed. Hence, conventional kidney function measures, such as glomerular filtration rate, do not adequately assess disease progression in ADPKD, especially in its early stages. Given the recent development of potential targeted therapies in ADPKD, it has become critically important to identify relevant biomarkers that can be used to determine the degree of disease progression and evaluate the effects of therapeutic interventions on the course of the disease. We review the current evidence to provide an informed perspective on whether total kidney volume (TKV) is a suitable biomarker for disease progression and whether TKV can be used as an efficacy end point in clinical trials. We conclude that because cystogenesis is the central factor leading to kidney enlargement, TKV appears to be an appropriate biomarker and is gaining wider acceptance. Several studies have identified TKV as a relevant imaging biomarker for monitoring and predicting disease progression and support its use as a prognostic end point in clinical trials.

The relationship between proton pump inhibitor use and serum magnesium concentration among hemodialysis patients: a cross-sectional study.

BACKGROUND: Observational data suggest that serum magnesium (Mg) concentration is inversely related to vascular calcification and hyperparathyroidism among patients with end-stage renal disease (ESRD). In recent years, there have been several case reports of hypomagnesemia due to use of proton-pump inhibitors (PPI), with the hypomagnesemia attributed to inappropriate gastrointestinal (GI) Mg loss. We hypothesized that the tendency to GI Mg loss is more common than is currently reported. Since patients with ESRD have little to no renal Mg loss to affect serum Mg concentration, dialysis patients are an interesting population in whom to study the relationship between PPI use and serum Mg levels. METHODS: Using a single-center cross-sectional design, we studied 155 prevalent hemodialysis (HD) patients. Serum Mg concentration for each patient was determined based on the mean of 3 consecutive serum Mg levels drawn at 6 week intervals. PPI use at the time of the blood tests was documented. The relationship between PPI use and Mg concentration was determined in unadjusted analyses, as well as after adjustment for age, gender, race, cause of ESRD, diabetes, time on HD and dialysate Mg concentration. RESULTS: 55 % of patients were on PPIs at the time of the study. The majority of patients (62 %) used a dialysate Mg (in mmol/L) of 0.5, and the remainder (38 %) used a dialysate Mg of 0.375. Serum Mg levels were significantly lower among PPI users vs. non-users (0.93 vs. 1.02 mmol/L, p < 0.001). This finding persisted after stratifying for dialysate Mg concentration, and after multivariable adjustment (p < 0.001). In addition, more PPI users vs. non-users had a Mg level < 1 mmol/L (79 % vs. 43 %) and a Mg level < 0.8 mmol/L (16 % vs. 4 %). There was a non-significant trend toward increased time on PPI being associated with lower serum Mg levels (p = 0.067). CONCLUSION: Among HD patients, PPI users have lower serum Mg levels as compared with non-users. Further research is required to determine whether the magnitude of change in Mg levels among PPI users is associated with adverse outcomes.

Risk of serious gastrointestinal bleeding in living kidney donors.

Individuals with moderate-to-severe reduced renal function have greater risk of gastrointestinal bleeding than those with normal renal function. We conducted a retrospective matched cohort study to assess whether living kidney donors share a similar risk. We reviewed pre-donation charts for living kidney donations from 1992 to 2009 in Ontario, Canada, and linked this information to healthcare databases. We selected healthy non-donors from the general population and matched ten non-donors to every donor. Of the 2009 donors and 20,090 matched non-donors, none had evidence of gastrointestinal bleeding prior to cohort entry. The cohort was followed for a median of 8.4 yr (maximum 19.7 yr; loss to follow-up <7%). There was no significant difference in the rate of hospitalization with gastrointestinal bleeding in donors compared to non-donors (18.5 vs. 14.9 events per 10,000 person-years; rate ratio 1.24; 95% confidence interval [CI] 0.85-1.81). Similar results were obtained when we assessed the time to first hospitalization with gastrointestinal bleeding (hazard ratio 1.25, 95% CI 0.87-1.79). In conclusion, we found living kidney donation was not associated with a higher risk of hospitalization with gastrointestinal bleeding. These results are reassuring for the safety of the practice.

Mid-term outcome and angiographic follow-up of endarterectomy of the left anterior descending artery in patients undergoing coronary artery bypass surgery.

BACKGROUND AND AIM: With the advancement of percutaneous coronary interventions (PCIs), more patients with diffuse coronary artery disease are referred for coronary artery bypass graft (CABG) surgery. The use of coronary endarterectomy may be useful in such cases. We reviewed our experience with left anterior descending artery endarterectomy as an adjunct to conventional CABG. METHODS: Between June 2005 and 2011, 58 consecutive patients underwent left anterior descending artery endarterectomy as an adjunct to CABG. These were matched to 58 cases based on age, gender, and Parsonnet score. All data were collected prospectively in a departmental database. Postoperative complications and in-hospital mortality were analyzed. Survival curves were produced. RESULTS: There was one death in the endarterectomy group (1.7%) from liver failure. There was no significant difference in postoperative complications (especially perioperative myocardial infarction) between the two groups with similar hospital mortality. Computed tomography (CT) angiography was performed in 24 patients with endarterectomy (41%), which showed 100% patency of the left internal mammary artery graft to the left anterior descending artery. Survival and freedom from intervention at a mean follow-up of 4.2 years were similar. CONCLUSIONS: In patients with diffuse disease, the use of endarterectomy is a safe technique with no increase in short-term morbidity or mortality. Mid-term results are similar to nonendarterectomized patients. This technique is useful in patients with diffuse coronary artery disease.

Global small bowel motility: assessment with dynamic MR imaging.

PURPOSE: To assess the repeatability in human volunteers of software-quantified small bowel motility captured with magnetic resonance (MR) imaging and to test the ability to detect changes in motility induced by pharmacologic agents. MATERIALS AND METHODS: The study was approved by the Royal Free Research Ethics Committee, and all subjects gave full written informed consent. Twenty-one healthy volunteers (14 men, seven women; mean age, 28 years) underwent cine MR imaging with a three-dimensional balanced turbo field-echo sequence to capture small bowel motility. Volume blocks (15 cm thick) were acquired every second during a 20-second breath hold. A randomized, blinded, placebo-controlled crossover study of either 0.5 mg neostigmine or saline (n = 11) or 20 mg intravenous butylscopolamine or saline (n = 10) was performed with motility MR imaging at baseline and repeated at a mean of 4 weeks (range, 2-7 weeks). Two readers independently drew regions of interest around the small bowel, and motility was quantified by using a registration algorithm that provided a global motility metric in arbitrary units. Repeatability of the motility measurements at baseline was assessed by using Bland-Altman and within-subject coefficient of variation measures. Changes in mean motility measurements after drug administration were compared with those after placebo administration by using paired t testing. RESULTS: The repeatability between baseline measurements of motility was high; the Bland-Altman mean difference was -0.0025 (range, 0.28-0.4), the 95% limit of agreement was ±0.044 arbitrary units (au), and the within-subject coefficient of variation was 4.9%. Measured motility with neostigmine (mean, 0.39 au) was significantly higher than that with placebo (mean, 0.34 au; P < .001), whereas that with butylscopolamine (mean, 0.13 au) was significantly lower than that with placebo (mean, 0.30 au; P < .001). CONCLUSION: Quantification of small bowel motility with use of MR imaging in healthy volunteers is repeatable and sensitive to changes induced by means of pharmacologic manipulation. SUPPLEMENTAL MATERIAL: http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.13130151/-/DC1.

Predictors of publication of randomized controlled trials in nephrology.

BACKGROUND AND AIMS: Changes in clinical practice based on research findings are dependent on the dissemination of information, which is a goal at national meetings. Given that evidence for many interventions in nephrology is lacking, it is important to determine predictors of publication of randomized controlled trials (RCTs) presented as abstracts at national conferences. MATERIALS AND METHODS: All abstracts submitted to the American Society of Nephrology (ASN) meeting 2005 were reviewed to identify completed RCTs. Univariate logistic regression was used to compare characteristics between published RCTs until June 2010 and those not published. Time to publication was calculated. RESULTS: 73 completed RCTs were presented out of 4,280 abstracts. 53% of these were published; median time to publication was 24 months (13.36 IQR). Oral presentations were published more frequently (OR 3.66, p = 0.01) as well as those with stated industry funding (OR 2.92, p = 0.03) and larger sample sizes (OR 2.1, p = 0.01). Blinded RCTs had ~ 4 times the odds of being published. Only ten RCTs used clinical endpoints such as death, hospitalizations etc.; however, all reached publication. CONCLUSIONS: Almost 50% of RCTs presented at the ASN 2005 meeting were not published within the studied time-frame. Well-conducted RCTs enhance the body of evidence needed to care for patients, if published. It is important to identify characteristics associated with non-publication, as above, to help us perform and report our studies better.

Elevated troponin I levels but not low grade chronic inflammation is associated with cardiac-specific mortality in stable hemodialysis patients.

BACKGROUND: Elevated cardiac troponin I (TnI) levels are associated with all-cause mortality in stable hemodialysis patients. Their relationship to cardiac-specific death has been inconsistent, and the reason for their elevation is not well understood. We hypothesized that elevated TnI levels in chronic stable hemodialysis patients more specifically track with cardiac mortality, and this mechanism is independent of other contributors of cardiac mortality, such as inflammation. METHODS: We conducted a single-centre, cohort study of prevalent hemodialysis patients at a tertiary care hospital. Plasma TnI levels were measured with routine monthly blood tests in clinically stable patients for two consecutive months. Plasma TnI was measured by immunoassay and a value above the laboratory reference range (0.06 µg/L) was considered elevated. The primary outcome of death was adjudicated separately for this study, and classified as cardiac, non-cardiac, or unknown. Cox proportional hazard models were used to examine the association of TnI with the all-cause and cardiac-specific mortality, adjusting for potential confounders, including C-reactive protein (CRP) as a marker of inflammation. RESULTS: Of 133 patients followed for a median of 1.7 years, there were 38 deaths (58% non-cardiac, 39% cardiac, 3% unknown). Elevated TnI was associated with adjusted HR for all-cause mortality of 2.57 (95% CI 1.30-5.09) and an adjusted HR for cardiac death of 3.14 (95% CI 1.07-9.2), after accounting for age, time on dialysis, diabetes status, prior coronary artery disease history, and C-reactive protein. Although CRP was also independently associated with all-cause mortality, it did not add prognostic information to TnI for cardiac-specific death. CONCLUSION: Elevated TnI levels are independently associated with cardiac and all-cause mortality in asymptomatic hemodialysis patients. The mechanism for this risk is likely independent of inflammation, but may reflect chronic subclinical myocardial injury or unmask those with subclinical atherosclerotic heart disease. Whether those with elevated TnI levels may benefit from additional investigations or more aggressive therapies to treat cardiovascular disease remains to be determined.

Dialysis and Transplant Considerations in Autosomal Dominant Polycystic Kidney Disease.

Autosomal dominant polycystic kidney disease (ADPKD) is the fourth leading cause of kidney replacement therapy. Unfortunately, the need for dialysis or kidney transplantation is a foreseeable outcome for many patients affected by ADPKD. We review some of the unique issues that should be considered in the management of patients with ADPKD who require dialysis or kidney transplantation. The choice of dialysis modality may be influenced by the enlarged kidneys and liver, but peritoneal dialysis should not be excluded as an option, as studies do not consistently show that there is an increased risk for technique failure or peritonitis. The optimal kidney replacement therapy option remains kidney transplantation; however, nephrectomy may be needed if there is insufficient space for the allograft. Living donor candidates from at-risk families need to be excluded from carrying the disease either by diagnostic imaging criteria or genetic testing. Other potential transplant issues, such as malignancy and cardiovascular and metabolic risks, should also be recognized. Despite these issues, patients with ADPKD requiring dialysis or kidney transplantation generally have more favorable outcomes as compared to those with other causes of chronic kidney disease. Further studies are still needed to personalize the therapeutic approach for those receiving kidney replacement therapy and eventually improve clinical outcomes.

Long-term Care of Living Kidney Donors Needs a Better Model of Healthcare Delivery.

Every year, over 30,000 healthy individuals globally donate a kidney to a patient with kidney failure. These living kidney donors are at higher risk of some medical complications post-donation when compared with matched controls. Although the absolute risk of these complications is low, appropriate long-term care is essential to allow early detection and timely interventions. Some transplant centers follow living donors long-term, but many recommend that donors regularly see a primary care practitioner post-donation. However, primary care is currently not integrated with transplant centers, and the two often work in silos with little to no channels of communication with each other. As this model of care is suboptimal, existing evidence suggests that post-donation care and follow-up are inadequate. We argue for an integrated model of living donor care with stronger continuity and coordination between primary care and transplant centers that are developed with the input of all relevant stakeholders.