Risk Taking and Decision Making in Kidney Paired Donation: A Qualitative Study by Semistructured Interviews.

INTRODUCTION: Despite excellent outcomes of kidney paired donation (KPD), little is known about how a patient's frame (apply cognitive bias) or weight (attribute value) and concerns relating to risk, justice, and equity affect his or her decision-making process. MATERIALS AND METHODS: A pilot study consisting of 3 KPD transplant recipients and 3 KPD kidney donors in the last year was conducted to identify and explore themes in decision making and risk taking. The pilot study was followed by the main study comprised of 20 recipients who had already undergone KPD transplantation and 20 donors who had undergone donor nephrectomy. We conducted semistructured interviews in this cohort and analyzed the data thematically. Each donor-recipient pair was interviewed together to facilitate dyadic conversation and provide deeper insight into the decision-making process leading to transplant and donation. RESULTS: Common themes to both recipient and donor decision making included quality of life; characteristics of the unknown donor and post-transplant expectations. Recipient-specific themes included failure to reach life span milestones, experiences of fellow patients, and altruistic desire to expand the donor pool. Donor-specific themes included balancing existing life commitments with the recipient's need for a kidney, equity and mental accounting in kidney exchange (comparable quality of the kidney received versus the kidney donated), and logistical justice for the recipient. DISCUSSION: Donors and recipients frame and weight the concepts of risk, justice, and equity differently. This may have direct implications to facilitating patient-centered communication and engagement in KPD pairs.

Diabetes, hypertension, sanitation, and health education by high school students in Guyana, South America.

We initiated a program for early detection of diabetes and hypertension, the main causes of kidney failure in Guyana, South America. We trained local high school students with the goal that these students would stay in the villages for long-term, become health advocates and shift the reliance away from physicians. This project involved 7 high school students who were taught to monitor the health of one village of 1000-1500 population each. The program will be implemented for 3 years in which the entire population of seven villages (approximately 10,000 people) will be covered. This represents 1.3% population in Guyana. We present data from the pilot study from the sample of 619 people. The prevalence of diabetes mellitus was 13.9%. Among diabetics, 33.7% were using insulin and 86% oral hypoglycemic agents. Prevalence of hypertension was 29.4%, 63.2% were overweight and 17% were obese. About 9.9% patients were unaware about the existence of hypertension. We have shown in our study that high school students can be used to collect health data and monitor diabetes and hypertension. There was also a significant incidence of undetected diabetes and hypertension.

Mortality on the Kidney Waiting List and After Transplantation in Patients With Peripheral Arterial Disease: An Analysis of the United States Renal Data System.

BACKGROUND: Reports from the United States Renal Data System (USRDS) indicated that kidney transplantation, whether from a living donor (LD) or deceased donor (DD), offers survival advantage over being on the waiting list. Whether this is true for patients with peripheral arterial disease (PAD) is unknown given that patients with PAD have significant comorbidities. METHODS: We used a cohort of USRDS incident dialysis patients from 2001 to 2007, with follow-up through 2008. Patients with PAD younger than the age of 70 were included and divided into 3 groups; PAD waitlisted, PAD patients who received a first transplant from a DD, or PAD patients who received a first transplant from a LD. Time-dependent Cox regression models were used to compare differences in mortality. RESULTS: In this study, 23,699 incident dialysis patients met inclusion criteria; only 16.7% (n = 3964) were waitlisted, of which 8.9 % (n = 2121) underwent transplantation. Patient survival in the LD group at any time point was significantly better than being on the waiting list (P < .001). For DD, mortality was higher in the first year compared with waitlisted patients (P < .001), however, after 1 year survival did not differ as compared with remaining on the waiting list. After adjusting for confounders, the relative risk (RR) of dying was significantly higher for patients with history of severe vascular disease requiring amputation (RR, 1.45; 95% confidence interval [CI], 1.15-1.84) in the DD group. CONCLUSIONS: Kidney transplantation from a DD did not offer survival advantage over being on the waiting list, in part due to a higher rate of severe vascular disease. Careful patient selection may improve outcomes in the DD group.

Evaluation of non-adherence in patients undergoing dialysis and kidney transplantation: United States transplantation practice patterns survey.

INTRODUCTION: We performed a survey of United States transplantation centers to evaluate practice patterns in the assessment of nonadherence before and after kidney transplantation. METHODS: An electronically administered, anonymous survey was sent to 181 United Network for Organ Sharing (UNOS) approved transplantation centers in 2012. RESULTS: Seventy-nine centers completed our survey. Of them, 51.3% had a protocol to evaluate medication/dialysis adherence before the listing; most common (36.4%) was the Simplified Medication Adherence Questionnaire. As an alternative to a questionnaire, the most common measure of nonadherence was the number of missed hemodialysis sessions (77.0%). The most common reason for poor adherence to dialysis regimens was difficulty with transportation (81.3%). Also, 94.4% noted the lack of a questionnaire to evaluate adherence to medications but relied on drug levels (73.4%) and self report. Only 12.9% used a questionnaire for the measurement of quality of life (Karnofsky performance scale). Of the participating centers, 27.1% used a formal cognitive testing for potential living donors. A social worker was used by most centers for nonadherent patients. Respondents indicated that patients (in the pretransplantation state) were more compliant with dialysis than with medication regimens. Finally, 37.7% of respondents noted graft failure due to medication nonadherence in 15% to 29% of their patients. CONCLUSIONS: There was a significant variability in the methods of screening for nonadherence while the patient was on dialysis, during pretransplantation work up, and during post-transplantation follow-up examinations. We recommend that there should be a standardized technique to evaluate nonadherence to facilitate focused clinical trials to improve adherence.

Ethical dilemmas in patient selection for a new kidney transplant program in Guyana, South America.

INTRODUCTION: We describe ethical/moral issues in patient selection in a new living donor kidney transplant program in Guyana, South America. CASE REPORTS: Over 3 years, we screened 450 patients with chronic kidney disease among which 70 were suitable for kidney transplantation. There were five patients whose evaluations raised possible ethical dilemmas: one had nonadherence to dialysis; two of Guyanese origin living abroad wished to have the transplant performed in Guyana; a minor wished to donate to her mother; and another subject was considering commercialization of the transplant process. RESULTS: Since inception of the renal replacement program in 2008, we have completed 13 living kidney transplantations, 17 peritoneal dialysis placements, and 20 vascular access procedures. In the five patients wherein faced ethical dilemmas, three were rejected for consideration despite having living donors: one was nonadherent, the second excluded due to an attempt to commercialize the process, and the third, a minor who wished to donate to the mother. The other two patients were considered Guyanese ex-patriots acceptable for the program. DISCUSSION: The consequence of kidney failure in Guyana prior to introduction of renal replacement therapy was a virtual death sentence. These cases illustrate ethical dilemmas serving to throw into stark relief the implications of decisions made in a developing country versus those in a developing country.

Room temperature pulsatile perfusion of renal allografts with Lifor compared with hypothermic machine pump solution.

This pilot study compared the use of the Lifor Organ Preservation Medium (RTLF) at room temperature with hypothermic Belzer machine preservation solution (CMPS) and room in vitro temperature Belzer machine preservation solution (RTMPS) in a porcine model of uncontrolled donation after cardiac death (DCD). In this study, 5 porcine kidneys for each perfusate group were recovered under a DCD protocol. The kidneys were recovered, flushed, and placed onto a renal preservation system following standard perfusion procedures. The average flow rate for CMPS was 36.2 +/- 7.2549 mL/min, RTMPS was 90.2 +/- 9.7159 mL/min, and RTLF was 103.1 +/- 5.1108 mL/min. The average intrarenal resistance for CMPS was 1.33 +/- 0.1709 mm Hg/mL per minute, RTMPS was 0.84 +/- 0.3586 and RTLF was 0.39 +/- 0.04. All perfusion parameters were statistically significant (P < .05) at all time points for the CMPS when compared with both RTMPS and RTLF. All perfusion parameters for RTMPS and RTLF were equivalent for the first 12 hours; thereafter, RTLF became significantly better than RTMPS at 18 and 24 hours. It appears that both RTMPS and RTLF have equivalent perfusion characteristic for the initial 12 hours of perfusion, but LF continues to maintain a low resistance and high flow up to 24 hours. The results of this pilot study indicate that RTLF may represent a better alternative to pulsatile perfusion with CMPS and requires validation in an in vivo large animal transplant model.

Association between depression and nonadherence in recipients of kidney transplants: analysis of the United States renal data system.

INTRODUCTION: In our previous prospective single-center study, using validated self-administered instruments, we demonstrated correlation between depression and nonadherence in recipients of kidney transplants. The purpose of this study was to confirm our finding that depression was associated with nonadherence in a large database of transplant recipients for which we used the United States Renal Data System (USRDS). METHODS: We conducted a retrospective cohort study of 32,757 Medicare primary renal transplant recipients in the USRDS who underwent transplantation from January 1, 2000 to July 31, 2004 and were followed up through December 31, 2004, assessing Medicare claims showing depression and nonadherence based on codes of the International Classification of Diseases, 9th Revision. RESULTS: Logistic regression analysis (adjusted hazards ratio 1.69 with 95% confidence interval, 1.48-1.92) and log rank test (P < .0005) showed that there was a strong association of depression and nonadherence. Depression was associated with nonadherence, irrespective of the time of depression, whether it was pretransplantation (P < .001) or posttransplantation (P < .001). Nonadherence was also associated with black race (P < .001), younger age (P < .001), less HLA mismatch (P < .005), recipients of living kidneys and patients who underwent transplantation a longer time ago (P < .001). Furthermore, patients with 12 or less years of education were more nonadherent (P < .001). Among the transplant donor factors we investigated, donor black race (P < .001) and expanded criteria donor kidneys were strongly associated with nonadherence (P < .001). However, donor age and delayed graft function were not significantly associated with nonadherence. CONCLUSIONS: Future clinical trials of immunosuppressive therapy should assess the impact of depression on graft survival.

Noncompliance after kidney transplantation: a systematic review.

We performed a systematic review of the literature on medical noncompliance after kidney transplantation in the cyclosporine era. We wished to define commonalities that may help the clinician identify patients for early intervention. We found that patients who were at a higher risk of noncompliance after kidney transplants were younger, female, unmarried, and non-Caucasians. Patients who were recipients of living donor transplants and had been transplanted for a longer time with a history of a previous transplant were also at risk of noncompliance. We also found that patients displaying emotional problems, such as anxiety, hostility, depression, distress, lack of coping, and avoidant behaviors, were also at risk for noncompliance after kidney transplantation.

Influence of dialysis on post-transplant events.

INTRODUCTION: We examined the effect of haemodialysis (HD) or peritoneal dialysis (PD) on acute rejection, delayed graft function (DGF), graft and patient survival after cadaveric renal transplantation. MATERIALS AND METHODS: We carried out a retrospective analysis of 325 patients (cyclosporin [CyA]-based therapy) who had their first cadaver renal transplant between January 1991 and December 1996 and followed up for a mean of 61 +/- 26 months. They were divided into three groups: HD, PD and CD (where both PD and HD was used for at least 3 months). Delayed graft function was diagnosed if the patient needed dialysis in the first week post-transplant while primary non-function (PNF) was diagnosed if the kidney never achieved function. Graft rejection was confirmed by biopsy; early acute rejection (EAR) was defined as acute rejection occurring before 90 days and late acute rejection (LAR) as one after 90 d. RESULTS: A total of 183 patients had PD, 117 HD and 25 CD. The mean time period in which the patients were on dialysis for PD was 24 months, HD 34.5 months and CD 50.6 months (p < 0.01). The recipients were matched for age and gender. The donor variables (age, gender and cold ischaemia time) did not differ between the groups. The mean time for the development of first acute rejection following renal transplant in each group was as follows: PD group: 68.8 d, HD group: 81.3 d and CD group: 105 d (p = 0.08). The number of patients who developed EAR was 90 (49.2%) in PD group, 51 (43.6%) in HD group and 11 (56%) in CD group (p = 0.6); the number who developed LAR was nine in PD group (4.9%), six in HD group (5.1%) and one in CD group (4%) (p = 0.9). Fifty-six patients with PD had DGF compared with 58 with HD (p = 0.01). There was no difference in the number and severity of rejection episodes or DGF based on the duration of dialysis. The 5-yr survival of patients was 79% for PD, 81% HD and 78% CD groups (p = n.s), while the graft survival for PD group was 61%, HD group 63% and CD group 74% (p = n.s). SUMMARY: We could find no difference in the patient or graft survival between patients who had pre-transplant HD, PD or CD. There was no difference in the incidence of acute rejection episodes between the three groups of patients as well. However, we found a significantly higher rate of DGF in the HD versus PD patients.

Use of rapamycin in a transplant patient who developed cyclosporin neurotoxicity.

We describe the case of a paediatric kidney transplant patient who developed cyclosporin neurotoxicity on day 7 post-transplant. Consequently, her cyclosporin was stopped and she was commenced on rapamycin. Over the next 3 weeks her creatinine remained elevated and she had several episodes of biopsy proven rejection, despite increasing the initial dose of rapamycin by tenfold. Her whole blood rapamycin levels also remained well below the target range of 10-20 ng/ml. On day 38 post-transplant, the decision was made to add tacrolimus to her immunosuppression. At the same time, phenytoin, which had been commenced during her episode of cyclosporin neurotoxicity, was withdrawn. After this point her rapamycin blood levels rapidly increased to within the therapeutic range and she improved clinically. We propose that phenytoin, as a p450 cytochrome enzyme inducer, increased the metabolism of rapamycin in this patient and hence decreased the initial therapeutic effectiveness of this drug.

The impact of late acute rejection after cadaveric kidney transplantation.

BACKGROUND: Acute graft rejection (AR) following renal transplantation results in reduced graft survival. However, there is uncertainty regarding the definition, aetiology and long-term graft and patient outcome of AR occurring late in the post-transplant period. AIM: To determine if rejection episodes can be classified by time from transplantation by their impact on graft survival into early acute rejection (EAR) and late acute rejection (LAR). MATERIALS AND METHODS: 687 consecutive adult renal transplant recipients who received their first cadaveric renal transplant at a single centre. All received cyclosporine (CyA)-based immunosuppression, from 1984 to 1996, with a median follow-up of 6.9 yr. Details were abstracted from clinical records, with emphasis on age, sex, co-morbid conditions, HLA matching, rejection episodes, patient and graft survival. ANALYSIS: Patients were classified by the presence and time to AR from the date of transplantation. Using those patients who had no AR (NAR) as a baseline, we determined the relative risk of graft failure by time to rejection. The characteristics of patients who had no rejection, EAR and LAR were compared. RESULTS: Compared with NAR, the risk of graft failure was higher for those patients who suffered a rejection episode. A much higher risk of graft failure was seen when the first rejection episode occurred after 90 d. Thus, a period of 90 d was taken to separate EAR and LAR (relative risk of 3.06 and 5.27 compared with NAR as baseline, p<0.001). Seventy-eight patients (11.4%) had LAR, 271 (39.4%) had EAR and 338 (49.2%) had NAR. The mean age for each of these groups differed (LAR 39.6 yr, EAR 40.8 yr compared with NAR 44 yr, p<0.003). The 5-yr graft survival for those who had LAR was 45% and 10-yr survival was 28%. HLA mismatches were more frequent in those with EAR vs. NAR (zero mismatches in HLA-A: 36 vs. 24%, HLA-B: 35 vs. 23% and HLA-DR: 63 vs. 41%, p<0.003). There was no difference in mismatching frequency between NAR and LAR. CONCLUSIONS: AR had a deleterious impact on graft survival, particularly if occurring after 90 d. AR episodes should therefore be divided into early and late phases. In view of the very poor graft survival associated with LAR, it is important to gain further insight into the main aetiological factors. Those such as suboptimal CyA blood levels and non-compliance with medication should be further investigated with the aim of developing more effective immunosuppressive regimens in order to reduce the incidence of LAR.

A retroperitoneal bronchogenic cyst: a rare cause of a mass in the adrenal region.

This report documents a bronchogenic cyst presenting as an adrenal tumour in a 51 year old man with persistent epigastric pain. The cyst is regarded as a developmental abnormality of the primitive foregut, which typically occurs in the chest. Subdiaphragmatic, and retroperitoneal locations in particular, are unusual. The differential diagnosis of a bronchogenic cyst in the retroperitoneum includes cystic teratoma, bronchopulmonary sequestration, cysts of urothelial and mullerian origin, and other foregut cysts.