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Management of Arteriovenous Fistulas, Tunnelled Dialysis Catheters and Peritoneal Dialysis Catheters after Successful Kidney Transplantation
D. Palmes,F. W. Pelster,H. H. Wolters
Transplantationsmedizin , 2010,
Abstract: Arteriovenous fistula closure after successful kidney transplantation reduces local complications, e.g. steal phenomena or infections, and cardiac co-morbidities in renal transplant patients. It is recommended to perform an AV fistula closure after 6 to 12 months after successful kidney transplantation. The closure of native AV fistulas should be performed by resection of the anastomotic site with conserving the shunt vein whereas in patients with PTFE grafts the foreign material should be completely removed. Due its multiple complications, tunnelled dialysis catheters should be shortly removed after successful kidney transplantation. In order to prevent peritonitis, peritoneal dialysis catheter should be removed after 2 to 6 weeks after kidney transplantation.
A Systematic Review and Meta-Analysis of Utility-Based Quality of Life in Chronic Kidney Disease Treatments  [PDF]
Melanie Wyld ,Rachael Lisa Morton,Andrew Hayen,Kirsten Howard,Angela Claire Webster
PLOS Medicine , 2012, DOI: 10.1371/journal.pmed.1001307
Abstract: Background Chronic kidney disease (CKD) is a common and costly condition to treat. Economic evaluations of health care often incorporate patient preferences for health outcomes using utilities. The objective of this study was to determine pooled utility-based quality of life (the numerical value attached to the strength of an individual's preference for a specific health outcome) by CKD treatment modality. Methods and Findings We conducted a systematic review, meta-analysis, and meta-regression of peer-reviewed published articles and of PhD dissertations published through 1 December 2010 that reported utility-based quality of life (utility) for adults with late-stage CKD. Studies reporting utilities by proxy (e.g., reported by a patient's doctor or family member) were excluded. In total, 190 studies reporting 326 utilities from over 56,000 patients were analysed. There were 25 utilities from pre-treatment CKD patients, 226 from dialysis patients (haemodialysis, n = 163; peritoneal dialysis, n = 44), 66 from kidney transplant patients, and three from patients treated with non-dialytic conservative care. Using time tradeoff as a referent instrument, kidney transplant recipients had a mean utility of 0.82 (95% CI: 0.74, 0.90). The mean utility was comparable in pre-treatment CKD patients (difference = ?0.02; 95% CI: ?0.09, 0.04), 0.11 lower in dialysis patients (95% CI: ?0.15, ?0.08), and 0.2 lower in conservative care patients (95% CI: ?0.38, ?0.01). Patients treated with automated peritoneal dialysis had a significantly higher mean utility (0.80) than those on continuous ambulatory peritoneal dialysis (0.72; p = 0.02). The mean utility of transplant patients increased over time, from 0.66 in the 1980s to 0.85 in the 2000s, an increase of 0.19 (95% CI: 0.11, 0.26). Utility varied by elicitation instrument, with standard gamble producing the highest estimates, and the SF-6D by Brazier et al., University of Sheffield, producing the lowest estimates. The main limitations of this study were that treatment assignments were not random, that only transplant had longitudinal data available, and that we calculated EuroQol Group EQ-5D scores from SF-36 and SF-12 health survey data, and therefore the algorithms may not reflect EQ-5D scores measured directly. Conclusions For patients with late-stage CKD, treatment with dialysis is associated with a significant decrement in quality of life compared to treatment with kidney transplantation. These findings provide evidence-based utility estimates to inform economic evaluations of kidney therapies, useful for policy
If you can't comply with dialysis, how do you expect me to trust you with transplantation? Australian nephrologists' views on indigenous Australians' 'non-compliance' and their suitability for kidney transplantation
Kate Anderson, Jeannie Devitt, Joan Cunningham, Cilla Preece, Meg Jardine, Alan Cass
International Journal for Equity in Health , 2012, DOI: 10.1186/1475-9276-11-21
Abstract: Nineteen nephrologists, from eight renal units treating the majority of Indigenous Australian renal patients, were interviewed in 2005-06 as part of a larger study. Thematic analysis was undertaken to investigate how compliance factors in specialists' decision-making, and its implications for Indigenous patients' likelihood of obtaining transplants.Specialists commonly identified Indigenous patients as both non-compliers and high-risk transplant candidates. Definition and assessment of 'compliance' was neither formal nor systematic. There was uncertainty about the value of compliance status in predicting post-transplant outcomes and the issue of organ scarcity permeated participants' responses. Overall, there was marked variation in how specialists weighed perceptions of compliance and risk in their decision-making.Reliance on notions of patient 'compliance' in decision-making for transplant referral is likely to result in continuing disadvantage for Indigenous Australian ESKD patients. In the absence of robust evidence on predictors of post-transplant outcomes, referral decision-making processes require attention and debate.End-stage kidney disease (ESKD) affects Indigenous Australians disproportionately [1]. Transplantation is the optimal treatment [2], but there is a substantial and persistent disparity in transplants given to Indigenous and non-Indigenous patients [3]. The vast majority of Indigenous Australians with ESKD remain on life-long dialysis. Their lower probability of receiving a transplant is not fully explained by measurable clinical differences.Many Indigenous Australians share contextual factors that may detrimentally affect their engagement with the health system and their response to the significant personal demands imposed by dialysis regimens. As a group, they have higher levels of socioeconomic disadvantage, lower educational attainment and poorer health literacy [4]. Many Indigenous dialysis patients experience isolation and reduced engagemen
Access to kidney transplantation: outcomes of the non-referred
AlBugami Meteb M,Panek Romuald,Soroka Steven,Tennankore Karthik
Transplantation Research , 2012, DOI: 10.1186/2047-1440-1-22
Abstract: Background There is a concern that some, especially older people, are not referred and could benefit from transplantation. Methods We retrospectively examined consecutive incident end stage renal disease (ESRD) patients at our center from January 2006 to December 2009. At ESRD start, patients were classified into those with or without contraindications using Canadian eligibility criteria. Based on referral for transplantation, patients were grouped as CANDIDATE (no contraindication and referred), NEITHER (no contraindication and not referred) and CONTRAINDICATION. The Charlson Comorbidity Index (CCI) was used to assess comorbidity burden. Results Of the 437 patients, 133 (30.4%) were CANDIDATE (mean age 50 and CCI 3.0), 59 (13.5%) were NEITHER (age 76 and CCI 4.4), and 245 (56.1%) were CONTRAINDICATION (age 65 and CCI 5.5). Age was the best discriminator between NEITHER and CANDIDATES (c-statistic 0.96, P <0.0001) with CCI being less discriminative (0.692, P <0.001). CANDIDATES had excellent survival whereas those patients designated NEITHER and CONTRAINDICATION had high mortality rates. NEITHER patients died or developed a contraindication at very high rates. By 1.5 years 50% of the NEITHER patients were no longer eligible for a transplant. Conclusions There exists a relatively small population of incident patients not referred who have no contraindications. These are older patients with significant comorbidity who have a small window of opportunity for kidney transplantation.
Trends in the Management and Outcomes of Kidney Transplantation for Autosomal Dominant Polycystic Kidney Disease  [PDF]
Madhukar S. Patel,Praveen Kandula,David Wojciechowski,James F. Markmann,Parsia A. Vagefi
Journal of Transplantation , 2014, DOI: 10.1155/2014/675697
Abstract: Background. Autosomal dominant polycystic kidney disease (ADPKD) is the most common genetic disorder leading to end-stage renal failure. The objective of this study was to evaluate a longitudinal experience of kidney transplantation for ADPKD. Methods. A single center retrospective review of patients undergoing kidney transplantation was conducted, with comparisons across two time periods: early (02/2000–04/2007, ) and late (04/2007–08/2012, ). Results. Over the 13.5-year study period, 133 patients underwent transplantation for ADPKD. Overall, no significant difference between the early and late group with regard to intraoperative complications, need for reoperation, readmissions within 30 days, delayed graft function, and mortality was noted. There was a trend towards increase in one-year graft survival (early 93.1% versus late 100%, ). In the early group, 67% of recipients had undergone aneurysm screening, compared to 91% of recipients in the late group ( ). Conclusions. This study demonstrates consistent clinical care with a trend towards improved rates of one-year graft survival. Interestingly, we also note a significantly higher use of cerebral imaging over time, with the majority that were detected requiring surgical intervention which may justify the current practice of nonselective radiological screening until improved screening criteria are developed. 1. Introduction Autosomal dominant polycystic kidney disease (ADPKD) is a disorder characterized by the development of renal cysts that may result in end-stage renal failure. Two main genes, PKD1 and PKD2, are thought to be involved in the majority of cases [1]. Variability in the genetic phenotype of ADPKD patients, however, is thought to be due to the range of different genetic mechanisms as well as environmental factors thought to play a role in phenotypic expression [1]. In addition to affecting the kidneys, ADPKD has a number of extrarenal manifestations including cystic formation in other organs such as the liver, seminal vesicles, pancreas, and arachnoid membrane; vascular malformations such as intracranial aneurysms, thoracic aorta dissections, and coronary artery aneurysms; cardiac manifestations such as mitral valve prolapse; and a higher incidence of colonic diverticulosis and diverticulitis [1]. In those with end-stage renal disease, it is accepted that transplantation is the preferred treatment for ADPKD [1]. Of the patients on the kidney transplant waiting list as of December 31 2011, 7256 (8.4%) were listed due to cystic kidney disease and of the 16,055 renal transplants performed
The Mode of Pretransplant Dialysis Does Not Affect Postrenal Transplant Outcomes in African Americans
Amit Sharma,Todd L. Teigeler,Martha Behnke,Adrian Cotterell,Robert Fisher,Anne King,Todd Gehr,Marc Posner
Journal of Transplantation , 2012, DOI: 10.1155/2012/303596
Abstract: Background. In previous reports with a majority of Caucasian patients, peritoneal dialysis (PD) before kidney transplantation has been associated with poor outcomes and higher rates of graft thrombosis and infectious complications than hemodialysis (HD). We report our experience on the outcomes of prerenal transplant peritoneal dialysis in predominantly (73%) African American patient population. Methods. A retrospective data analysis of 401 kidney transplants performed at our center from 2000 to 2006 was performed. Adult recipients with at least three months of pretransplant HD or PD were included. Results. There were 339 patients on HD and 62 patients on PD. There was no difference in graft (=0.51) and patient survival (=0.52) at 1, 3, and 5-years. Patients on HD were more likely to experience delayed graft function than PD (38.8% versus 17.7%, <0.005). There was no difference in the incidence of vascular thrombosis or posttransplant infectious complications. When only the African American patients in the two groups were compared, there were no differences in graft or patient survival. Conclusions. Pretransplant peritoneal dialysis is associated with excellent patient and renal allograft outcomes in African Americans and does not predispose them to an increased risk of infectious or thrombotic complications.
Decreased Bone Mineral Density in Patients Submitted to Kidney Transplantation Is Related to Age, Body Mass Index, Time on Dialysis, and Hyperparathyroidism  [PDF]
Miguel Madeira,Mário Sérgio Zen,Paulo Gustavo Sampaio Lacativa,Carolina Hammes Torres,Ana Paula Pires Lázaro,Renato Torres Gon?alves,Laura Maria Carvalho de Mendon?a,Maria Lucia Fleiuss de Farias
Advances in Endocrinology , 2014, DOI: 10.1155/2014/716051
Abstract: Background. Renal transplantation (Tx) influences bone mineral density (BMD) by several mechanisms. The main objective of this study was to correlate BMD and risk factors associated with bone loss in patients submitted to kidney Tx. Methods. We evaluated 88 individuals after renal Tx (median time?=?31.5 months since Tx). All of them sustained glomerular filtration rate ≥60?mL/min/1.73?m2. BMD was measured by dual-energy X-ray absorptiometry (DXA, Prodigy-GE). Calcium, phosphate, albumin, creatinine, and intact parathormone (PTH) were measured at the same time. All statistical tests were two-sided and value less than 0.05 were accepted as significant for all analyses in this study. Results. Serum PTH was raised in 42% patients, but corrected calcium was normal in 83 patients. No fragility fracture was reported, but the overall prevalence of osteoporosis was 27.6% and lower than expected BMD (Z-score ≤ ?2.0 SD) was observed in 28.4%. Patients with lower than expected BMD had higher PTH levels. Conclusions. Older age, lower body mass index (BMI), longer time on dialysis, and elevated PTH levels were identified as the main factors associated with lower BMD. 1. Introduction Chronic kidney disease is caused by several conditions and has become a prevalent comorbidity. Renal transplantation (Tx) is the treatment of choice for most patients with end-stage renal disease (ESRD) [1]. Advances in immunosuppressive agents and transplant techniques during the last decades have led to improved long-term graft and patient survival. This fact resulted in both increases in transplant numbers and an increased recognition of previously neglected long-term complications of Tx, such as osteoporosis and fractures. Osteoporosis is prevalent in more than half of solid organ recipients and vertebral fractures are found in almost a third of patients [2]. Particularly during the early post-Tx period, kidney recipients experience a rapid loss of bone mass [3]. Rates of bone loss are greatest during the first 6–18 months after renal Tx and range from 4 to 9% at the spine and 5 to 8% at the hip [4]. Different factors have been associated to this bone disease. Chronic kidney disease-mineral and bone disorder (CKD-MBD) begins during the early stages of the disease and usually worsens during dialysis. Both pretransplantation bone disease and immunosuppressive therapy result in rapid bone loss and increased fracture rates [4, 5]. It is expected that parathormone (PTH) levels reach 50% of their initial values on the fourteenth day after renal Tx and that hyperparathyroidism (HPT) reverses
Health-related quality of life outcomes after kidney transplantation
Wolfgang Fiebiger, Christa Mitterbauer, Rainer Oberbauer
Health and Quality of Life Outcomes , 2004, DOI: 10.1186/1477-7525-2-2
Abstract: In summary HRQL is becoming more of an issue after renal transplantation. Whether a specific immunosuppressive protocol is superior to others in terms of HRQL remains to be determined.Health-related quality of life (HRQL) contains multiple aspects of health related issues from the patients' perspective including physical, psychological, and social functioning and overall well-being [1-3]. Numerous clinical trials have established the importance of HRQL in various diseases, and it is increasingly popular to evaluate disease-specific and generic HRQL in clinical trials as a measure of patients' subjective state of health.HRQL is also increasingly recognised as an important measure of outcome following solid organ transplantation. Along with significant quantitative improvements in patient and graft survival, HRQL has been appreciated as another valid outcome measurement.HRQL investigations take a broad view on subjective health issues and consider health as a puzzle of singular domains of well-being. The pieces of this puzzle are psychological and social aspects of well-being in addition to physical and mental health. Some of these pieces are evaluated on either a subjective or an objective basis, some domains by both dimensions [3].Kidney transplantation is the treatment of choice for end stage renal disease (ESRD). Advances in renal transplant procedures and immunosuppressive therapies have increased dramatically over the last decades, one year allograft survival rates are currently over 90 % [4]. The major goal of transplantation is the achievement of maximal quality and quantity of life while minimising the effects of disease and in renal transplantation also the costs of care. The units in which these socio-biological terms are reported depend on the condition that is being evaluated. Examples of these measures are quality-adjusted life years gained, disease-free life years gained, or healthy-year equivalents per unit cost of care. In renal transplantation the co
Comparative Survival and Economic Benefits of Deceased Donor Kidney Transplantation and Dialysis in People with Varying Ages and Co-Morbidities  [PDF]
Germaine Wong,Kirsten Howard,Jeremy R. Chapman,Steven Chadban,Nicholas Cross,Allison Tong,Angela C. Webster,Jonathan C. Craig
PLOS ONE , 2012, DOI: 10.1371/journal.pone.0029591
Abstract: Deceased donor kidneys for transplantation are in most countries allocated preferentially to recipients who have limited co-morbidities. Little is known about the incremental health and economic gain from transplanting those with co-morbidities compared to remaining on dialysis. The aim of our study is to estimate the average and incremental survival benefits and health care costs of listing and transplantation compared to dialysis among individuals with varying co-morbidities.
High-Urgency Renal Transplantation: Indications and Long-Term Outcomes  [PDF]
Lampros Kousoulas,Nikos Emmanouilidis,Wilfried Gwinner,Jürgen Klempnauer,Frank Lehner
Journal of Transplantation , 2013, DOI: 10.1155/2013/314239
Abstract: The concept of high-urgency (HU) renal transplantation was introduced in order to offer to patients, who are not able to undergo long-term dialysis treatment, a suitable renal graft in a short period of time, overcoming by this way the obstacle of the prolonged time spent on the waiting list. The goal of this study was to evaluate the patient and graft survivals after HU renal transplantation and compare them to the long-term outcomes of the non-high-urgency renal transplant recipients. The clinical course of 33 HU renal transplant recipients operated on at our center between 1995 and 2010 was retrospectively analyzed. The major indication for the HU renal transplantation was the imminent lack of access for either hemodialysis or peritoneal dialysis (67%). The patient survival of the study population was 67%, 56%, and 56%, whereas the graft survival was 47%, 35% and 35%, at 5, 10, and 15 years, respectively. In the comparison between our study population and the non-HU renal transplant recipients, our study population presented statistically significant lower patient survival rates. The HU renal transplant recipients also presented lower graft survival rates, but statistical significance was reached only in the 5-year graft survival rate. 1. Introduction Renal transplantation is the treatment of choice for patients with end-stage renal disease, as it increases the survival of the recipients and improves their quality of life, as compared to long-term dialysis treatment [1–3]. As the number of patients in need of renal transplantation rapidly increases, whereas the supply of organs available for transplantation stays stable or even decreases in some countries [4], the prolonged time spent on the waiting list for transplantation is nowadays a cardinal problem for the majority of patients and especially for those who are not able to undergo dialysis treatment or for those who develop severe complications of the end-stage renal disease [5–7]. To overcome this obstacle, the concept of high-urgency (HU) renal transplantation was introduced by Eurotransplant, in order to offer to this group of patients a renal graft in a short period of time. The major indications for a HU renal transplantation are the imminent lack of access for either hemodialysis or peritoneal dialysis and the inability of the patient to cope with dialysis with a high risk for suicide. Moreover, severe uremic polyneuropathy and severe bladder problems (such as hematuria and cystitis) due to kidney graft failure after a combined kidney-pancreas transplantation are also indications for a HU
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