The Motivations and Experiences of Living Kidney Donors: A Thematic Synthesis.
Am J Kidney Dis. 2012 Feb 3;
Authors: Tong A, Chapman JR, Wong G, Kanellis J, McCarthy G, Craig JC
Abstract
BACKGROUND: Living kidney donation is associated with better recipient outcomes compared with deceased kidney donation, but living kidney donors face the risk of physical and psychological complications. The aim of this study was to synthesize published qualitative studies of the experiences and perspectives of living kidney donors. METHODS: We conducted a systematic review and thematic synthesis of qualitative studies of motivations to donate and experiences after donation of living kidney donors. MEDLINE, Embase, PsycINFO, CINAHL, and reference lists of articles were searched to April 2011. RESULTS: 26 studies involving 478 donors were included. We identified 6 themes about the decision to donate: compelled altruism, inherent responsibility, accepting risks, family expectation, personal benefit, and spiritual confirmation. Three themes dominated the impact of donation and postdonation: renegotiating identity (including subthemes of fear and vulnerability, sense of loss, depression and guilt, new appreciation of life, and personal growth and self-worth), renegotiating roles (including subthemes of multiplicity of roles, unable to resume previous activities, and hero status), and renegotiating relationships (including subthemes of neglect, proprietorial concern, strengthened family and recipient bonds, and avoidance of recipient indebtedness). CONCLUSIONS: Kidney donation has a profound and multifaceted impact on the lives of donors and requires them to renegotiate their identity, roles, and relationships. Strategies to safeguard against unwarranted coercion, and to maximize donor resilience, capacity to negotiate their multiple roles as a patient and carer, emotional fortitude, and ability to have balanced expectations and relationships with the recipient and the family are needed to ultimately protect the safety and well-being of living kidney donors.
PMID: 22305757 [PubMed - as supplied by publisher]
Age and the Associations of Living Donor and Expanded Criteria Donor Kidneys With Kidney Transplant Outcomes.
Am J Kidney Dis. 2012 Feb 3;
Authors: Molnar MZ, Streja E, Kovesdy CP, Shah A, Huang E, Bunnapradist S, Krishnan M, Kopple JD, Kalantar-Zadeh K
Abstract
BACKGROUND: Recent studies show a survival advantage with kidney transplant in elderly patients compared with those on dialysis therapy. STUDY DESIGN: In our present study, we examined and compared the association of expanded criteria donor (ECD) kidney and living kidney donation with the outcome of kidney transplant across different ages, including elderly recipients. SETTING & PARTICIPANTS: Using the Scientific Registry of Transplant Recipients, we identified 145,470 adult kidney transplant patients. Mortality and death-censored transplant failure risks were estimated by Cox proportional regression analyses during follow-up with a median of 3.9 years. PREDICTORS: ECD kidney and living kidney donation and age compared with others. OUTCOMES: Mortality and death-censored transplant failure risk. RESULTS: Patients were aged 45 ± 16 years and included 40% women and 19% patients with diabetes. Compared with transplant recipients 55 to younger than 65 years, the fully adjusted death-censored transplant failure risk was higher in patients 75 years and older (HR, 1.30; 95% CI, 1.09-1.56), 35 to younger than 55 years (HR, 1.13; 95% CI, 1.08-1.17), and 18 to younger than 35 years (HR, 1.64; 95% CI, 1.57-1.71). Compared with non-ECD kidneys, ECD kidneys were significant predictors of mortality in nonelderly patients (18-<35 years: HR, 1.46 [95% CI, 1.19-1.77]; 35-<55 years: HR, 1.23 [95% CI, 1.14-1.32]; and 55-<65 years: HR, 1.26 [95% CI, 1.15-1.38]) and patients 65 to younger than 70 years (HR, 1.20; 95% CI, 1.05-1.36), but not in other groups of elderly patients (HRs of 1.12 [95% CI, 0.93-1.36] for 70-<75 years and 1.04 [95% CI, 0.74-1.47] for ≥75 years). Similar results were found for risk of transplant loss. Compared with deceased donor kidneys, a living donor kidney was associated with better survival in all age groups and lower transplant loss risk in patients younger than 70 years. LIMITATIONS: Unmeasured confounders cannot be adjusted for. CONCLUSIONS: For deceased donors, ECD kidneys are not associated with increased mortality or transplant failure in recipients older than 70 years. For all types of donors, the persistent association between living donor kidneys and lower all-cause mortality across all ages suggests that, if possible, elderly patients gain longevity from living donor kidney transplant.
PMID: 22305759 [PubMed - as supplied by publisher]
BACKGROUND: Cystatin C level predicts mortality more strongly than serum creatinine level. It is unknown whether this advantage extends to other outcomes, such as kidney failure, or whether other novel renal filtration markers share this advantage in predicting outcomes. STUDY DESIGN: Observational cohort study. SETTING & PARTICIPANTS: 9,988 participants in the Atherosclerosis Risk in Communities (ARIC) Study, a population-based study in 4 US communities, followed for approximately 10 years. PREDICTORS: Serum creatinine-based estimated glomerular filtration rate calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation (eGFR(CKD-EPI)) and cystatin C, β-trace protein (BTP), and β(2)-microglobulin (B2M) levels. OUTCOMES: Mortality, coronary heart disease, heart failure, and kidney failure. RESULTS: Higher cystatin C and B2M concentrations were associated more strongly with mortality (n = 1,425) than BTP level and all were associated more strongly than eGFR(CKD-EPI) (adjusted HR for the upper 6.7 percentile compared with the lowest quintile: 1.6 [95% CI, 1.3-1.9] for eGFR(CKD-EPI), 2.9 [95% CI, 2.3-3.6] for cystatin C level, 1.9 [95% CI, 1.5-2.4] for BTP level, and 3.0 [95% CI, 2.4-3.8] for B2M level). Similar patterns were observed for coronary heart disease (n = 1,279), heart failure (n = 803), and kidney failure (n = 130). The addition of cystatin C, BTP, and B2M levels to models including eGFR(CKD-EPI) and all covariates, including urinary albumin-creatinine ratio, significantly improved risk prediction for all outcomes (P < 0.001). LIMITATIONS: No direct measurement of GFR. CONCLUSIONS: B2M and, to a lesser extent, BTP levels share cystatin C’s advantage over eGFR(CKD-EPI) in predicting outcomes, including kidney failure. These additional markers may be helpful in improving estimation of risk associated with decreased kidney function beyond current estimates based on eGFR(CKD-EPI).
PMID: 22305758 [PubMed - as supplied by publisher]
Trajectories of Kidney Function Decline in the 2 Years Before Initiation of Long-term Dialysis.
Am J Kidney Dis. 2012 Feb 3;
Authors: O’Hare AM, Batten A, Burrows NR, Pavkov ME, Taylor L, Gupta I, Todd-Stenberg J, Maynard C, Rodriguez RA, Murtagh FE, Larson EB, Williams DE
Abstract
BACKGROUND: Little is known about patterns of kidney function decline leading up to the initiation of long-term dialysis. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: 5,606 Veterans Affairs patients who initiated long-term dialysis in 2001-2003. PREDICTOR: Trajectory of estimated glomerular filtration rate (eGFR) during the 2-year period before initiation of long-term dialysis. OUTCOMES & MEASUREMENTS: Patient characteristics and care practices before and at the time of dialysis initiation and survival after initiation. RESULTS: We identified 4 distinct trajectories of eGFR during the 2-year period before dialysis initiation: 62.8% of patients had persistently low level of eGFR <30 mL/min/1.73 m(2) (mean eGFR slope, 7.7 ± 4.7 [SD] mL/min/1.73 m(2) per year), 24.6% had progressive loss of eGFR from levels of approximately 30-59 ml/min/1.73 m(2) (mean eGFR slope, 16.3 ± 7.6 mL/min/1.73 m(2) per year), 9.5% had accelerated loss of eGFR from levels >60 mL/min/1.73 m(2) (mean eGFR slope, 32.3 ± 13.4 mL/min/1.73 m(2) per year), and 3.1% experienced catastrophic loss of eGFR from levels >60 mL/min/1.73 m(2) within 6 months or less. Patients with steeper eGFR trajectories were more likely to have been hospitalized and have an inpatient diagnosis of acute kidney injury. They were less likely to have received recommended predialysis care and had a higher risk of death in the first year after dialysis initiation. CONCLUSIONS: There is substantial heterogeneity in patterns of kidney function loss leading up to the initiation of long-term dialysis perhaps calling for a more flexible approach toward preparing for end-stage renal disease.
PMID: 22305760 [PubMed - as supplied by publisher]
Differences Between Dialysis Modality Selection and Initiation.
Am J Kidney Dis. 2012 Feb 2;
Authors: Liebman SE, Bushinsky DA, Dolan JG, Veazie P
Abstract
BACKGROUND: Although dialysis modality education is associated with higher rates of peritoneal dialysis (PD) use, some patients start hemodialysis (HD) therapy despite initially selecting PD as their modality of choice. This study seeks to identify predictors of this discrepancy. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: 217 patients who received dialysis modality education at the University of Rochester between January 2004 and September 2009 and subsequently started dialysis therapy. PREDICTORS: Demographic (age, race, sex, and timing of education), social (education, income, insurance, marital, employment, and smoking status), and clinical data (estimated glomerular filtration rate, cause of end-stage renal disease [ESRD], number of comorbid conditions, and number of nephrology visits). OUTCOME: HD use at initiation and day 91 of dialysis therapy in patients initially selecting PD. RESULTS: Of 217 patients receiving education and starting dialysis therapy, at the time of education, 124 chose PD, 52 were undecided, and 41 chose HD. Modality distribution at the time of dialysis therapy initiation was 150 with HD and 67 with PD. Of 124 patients who chose PD at the time of education, 59 started dialysis therapy with PD and 65 started with HD. On day 91, a total of 60 patients were on PD therapy and 55 were on HD therapy. Nine patients had either died, undergone transplant, or not yet reached 91 days of dialysis therapy. On multivariable analysis, nonglomerular cause of ESRD, age older than 75 years, and not being employed predicted starting with HD therapy, whereas age older than 75 years, nonwhite race, and nonglomerular cause of ESRD predicted HD use at day 91. LIMITATIONS: Single-center observational study. CONCLUSIONS: This study shows that patients choosing PD after dialysis education may not start with this modality and identifies several predictors of this mismatch. Further investigation into predictors of this discrepancy and strategies promoting a PD start in patients selecting this modality are warranted.
PMID: 22305859 [PubMed - as supplied by publisher]
Addition of Plasma Exchange to Glucocorticosteroids for the Treatment of Severe Henoch-Schönlein Purpura in Adults: A Case Series.
Am J Kidney Dis. 2012 Jan 31;
Authors: Augusto JF, Sayegh J, Delapierre L, Croue A, Tollis F, Cousin M, Subra JF
Abstract
BACKGROUND: Adult Henoch-Schönlein purpura (HSP) has been associated with poor outcome and end-stage renal disease in >20% of cases. Although the benefit of adding another immunosuppressant to steroids in severe adult HSP has not been shown, the benefit of plasma exchange (PE) therapy has been poorly evaluated. STUDY DESIGN: Case series. SETTING & PARTICIPANTS: 11 consecutive patients with severe and newly diagnosed HSP since 1988 who were treated with steroids and PE. OUTCOME & MEASUREMENT: Patients’ characteristics and outcome were analyzed. Birmingham Vasculitis Activity Score (BVAS), estimated glomerular filtration rate (eGFR), and proteinuria were measured at baseline, at the end of PE treatment, at months 6 and 12, and at the last visit. Side effects of corticoid treatment and PE were recorded. RESULTS: 11 patients were identified in 1988-2010. Patients received intravenous corticoid pulses in 64% of cases, followed by oral prednisone for a median of 6.6 months. They received a median of 12 PE sessions. BVAS, eGFR, and proteinuria improved significantly between baseline and the last PE at a median of 2 months. PE sessions were well tolerated, except in one patient who developed central catheter-associated septicemia. One patient required dialysis therapy 15 days after HSP diagnosis and did not recover kidney function. At the last medical evaluation at a mean follow-up of 6 years, median eGFR and proteinuria were 83 ± 22 mL/min/1.73 m(2) and protein excretion of 140 ± 10 mg/d, respectively. 3 women had pregnancy without complications. LIMITATIONS: This case series did not have a control group. CONCLUSIONS: The combination of PE and corticoid therapy in severe forms of HSP was associated with fast improvement and good long-term outcome.
PMID: 22300649 [PubMed - as supplied by publisher]
Decreased Kidney Function Among Agricultural Workers in El Salvador.
Am J Kidney Dis. 2012 Jan 31;
Authors: Peraza S, Wesseling C, Aragon A, Leiva R, García-Trabanino RA, Torres C, Jakobsson K, Elinder CG, Hogstedt C
Abstract
BACKGROUND: An epidemic of chronic kidney disease of unknown cause has emerged along the Pacific coast of Central America, particularly in relatively young male sugarcane workers. In El Salvador, we examined residence and occupations at different altitudes as surrogate risk factors for heat stress. STUDY DESIGN: Cross-sectional population-based survey. SETTING & PARTICIPANTS: Populations aged 20-60 years of 5 communities in El Salvador, 256 men and 408 women (participation, 73%): 2 coastal communities with current sugarcane and past cotton production and 3 communities above 500 m with sugarcane, coffee, and service-oriented economies. PREDICTOR: Participant sex, age, residence, occupation, agricultural history by crop and altitude, and traditional risk factors for CKD. OUTCOMES: Serum creatinine (SCr) level greater than the normal laboratory range for sex, estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m(2), and proteinuria categorized as low (protein excretion ≥30-<300 mg/dL) and high grade (≥300 mg/dL). RESULTS: Of the men in the coastal communities, 30% had elevated SCr levels and 18% had eGFR <60 mL/min/1.73 m(2) compared with 4% and 1%, respectively, in the communities above 500 m. For agricultural workers, prevalences of elevated SCr levels and eGFR <60 mL/min/1.73 m(2) were highest for coastal sugarcane and cotton plantation workers, but were not increased in sugarcane workers at 500 m or subsistence farmers. Women followed a weaker but similar pattern. Proteinuria was infrequent, of low grade, and not different among communities, occupations, or sexes. The adjusted ORs of decreased kidney function for 10-year increments of coastal sugarcane or plantation work were 3.1 (95% CI, 2.0-5.0) in men and 2.3 (95% CI, 1.4-3.7) in women. LIMITATIONS: The cross-sectional nature of the study limits etiologic interpretations. CONCLUSION: Agricultural work on lowland sugarcane and cotton plantations was associated with decreased kidney function in men and women, possibly related to strenuous work in hot environments with repeated volume depletion.
PMID: 22300650 [PubMed - as supplied by publisher]
Longitudinal Progression Trajectory of GFR Among Patients With CKD.
Am J Kidney Dis. 2012 Jan 25;
Authors: Li L, Astor BC, Lewis J, Hu B, Appel LJ, Lipkowitz MS, Toto RD, Wang X, Wright JT, Greene TH
Abstract
BACKGROUND: The traditional paradigm of glomerular filtration rate (GFR) progression in patients with chronic kidney disease (CKD) is a steady nearly linear decline over time. We describe individual GFR progression trajectories over 12 years of follow-up in participants in the African American Study of Kidney Disease and Hypertension (AASK). STUDY DESIGN: Longitudinal observational study. SETTING & PARTICIPANTS: 846 AASK patients with at least 3 years of follow-up and 8 GFR estimates. MEASUREMENTS: Longitudinal GFR estimates from creatinine-based equations. PREDICTORS: Patient demographic and clinical features. OUTCOMES: Probability of a nonlinear trajectory and probability of a period of nonprogression calculated for each patient from a Bayesian model of individual estimated GFR (eGFR) trajectories. RESULTS: 352 (41.6%) patients showed a >0.9 probability of having either a nonlinear trajectory or a prolonged nonprogression period; in 559 (66.1%), the probability was >0.5. Baseline eGFR >40 mL/min/1.73 m(2) and urine protein-creatinine ratio <0.22 g/g were associated with a higher likelihood of a nonprogression period. 74 patients (8.7%) had both a substantial period of stable or increasing eGFR and a substantial period of rapid eGFR decrease. LIMITATIONS: Clinical trial population; absence of direct GFR measurements. CONCLUSIONS: In contrast to the traditional paradigm of steady GFR progression over time, many patients with CKD have a nonlinear GFR trajectory or a prolonged period of nonprogression. These findings highlight the possibility that stable kidney disease progression can accelerate and, conversely, provide hope that CKD need not be relentlessly progressive. These results should encourage researchers to identify time-dependent factors associated with periods of nonprogression and other desirable trajectories.
PMID: 22284441 [PubMed - as supplied by publisher]
Variation in Oral Calcitriol Response in Patients With Stages 3-4 CKD.
Am J Kidney Dis. 2012 Jan 27;
Authors: Shoben AB, Levin G, de Boer IH, Yeung C, Watnick S, Ayers E, Kestenbaum B
Abstract
BACKGROUND: Oral calcitriol decreases parathyroid hormone (PTH) concentrations in patients who have chronic kidney disease (CKD); however, treatment response is highly variable. We evaluated whether patient characteristics affect the PTH response to oral calcitriol in nondialysis patients with CKD in a clinic-based setting. STUDY DESIGN: Cohort study. SETTING & PARTICIPANTS: This study included 379 new oral calcitriol users in the Veterans’ Affairs Northwest Health Network. All had stages 3-4 CKD, hyperparathyroidism, and a serum PTH measurement before and 1-6 months after initiating oral calcitriol therapy. PREDICTORS: Patient-level characteristics hypothesized to affect calcitriol response: race, body size, concurrent medications, and kidney function. OUTCOMES: Relative decrease in serum PTH concentration after starting oral calcitriol therapy. MEASUREMENTS: Data were abstracted from the Veterans’ Affairs Northwest Health Network (VISN 20) Data Warehouse, which includes electronic pharmacy and laboratory records. RESULTS: Mean estimated glomerular filtration rate was 30 mL/min/1.73 m(2) and mean initial PTH concentration was 199 pg/mL. Regular- (0.25 μg/d) and low-dose (<0.25 μg/d) oral calcitriol were associated with on average 23% and 13% relative decreases in serum PTH concentrations, respectively. After adjustment for calcitriol dosage, initial PTH concentration, and time to follow-up measurement, African American race was associated with a blunted calcitriol response (geometric mean final PTH value, 26% higher; 95% CI, 8%-47%). Serum albumin concentration <3.5 g/dL also was associated with a diminished calcitriol response (geometric mean final PTH, 19% higher; 95% CI, 6%-35%). Although numbers were small, concurrent use of benzodiazepines and nonactivated vitamin D supplements was associated with a significantly greater PTH response. LIMITATIONS: Clinic-based study is limited by the availability of PTH measurements after starting calcitriol therapy. Study of a predominantly older male population. CONCLUSIONS: In patients with stages 3-4 CKD, African American race and low serum albumin level are associated with a diminished PTH response to oral calcitriol.
PMID: 22285224 [PubMed - as supplied by publisher]
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