Background: Compared with the general population, kidney transplant recipients (KTRs) frequently visit the emergency department (ED), but much less is known about the characteristics of ED presentations requiring ambulance transport and the impact on subsequent outcomes for KTRs.
Objectives: To identify predictors of ambulance transport to the ED (ambulance-ED) and outcomes (graft failure and mortality) for those who experienced an ambulance-ED event in a cohort of KTRs.
Design: Retrospective cohort study of incident, adult KTRs receiving a transplant from 2008 to 2020.
Setting: Nova Scotia, Canada.
Patients: Adult (≥18 years), Nova Scotian KTRs affiliated with the Atlantic Canada Multi-Organ Transplant Program.
Measurements: Ambulance-ED events were captured for all transplant recipients (following the day of discharge from their initial transplant admission) using electronic records (provided by Emergency Health Services, the sole provider of emergency medical services for Nova Scotia). Ambulance-ED was defined as ambulance transport to the ED following a 911 call; interfacility transfers were excluded. Predictors of ambulance-ED included recipient, donor, immunological, and perioperative characteristics (pertaining to the initial admission for kidney transplantation). Outcomes included graft failure and mortality.
Methods: Predictors of ambulance-ED were analyzed using a multivariable negative binomial regression model and reported using incidence rate ratios (IRRs) and 95% confidence intervals (CIs). The risk of death/graft failure for those with an ambulance-ED within 30 days of hospital discharge following transplantation was analyzed using an adjusted Cox survival analysis and reported using hazard ratios (HRs) and 95% CIs.
Results: A total of 418 patients received a transplant during the study period. A total of 179 (42.8%) experienced one or more ambulance-ED events. Female sex (IRR = 1.60; 95% CI = 1.12-2.29), kidney failure secondary to diabetes (IRR = 2.52; 95% CI = 1.19-5.31), and donor age ≥45 (IRR = 1.50; 95% CI = 1.04-2.15) were all associated with ambulance-ED. There was no significant increase in the risk of death/graft failure for those that experienced ambulance-ED within 30 days of hospital discharge following transplantation (HR = 1.31; 95% CI = 0.44-3.94).
Limitations: A limitation of this study was that ambulance-ED is not a perfect surrogate marker of acute care needs in a population. Important determinants of health such as living situation and socioeconomic status were not available in this data set.
Conclusions: This study highlights the burden of ambulance use for KTRs and provides insight into the need for more optimal follow-up in certain patient subgroups who are at particularly high risk.
Background: Transplanting less-than-ideal (LTI) kidneys could help optimize organ utilization, but little is known about how patients and caregivers perceive the allocation process, waitlist, or LTI kidneys.
Objective: To explore the perspectives of patients and caregivers on the Canadian kidney transplant allocation process, waitlist, and LTI kidneys.
Design: Electronic survey.
Setting: Canada.
Patients: Transplant recipients, candidates, and caregivers.
Methods: A bilingual electronic national survey was administered from January to March 2024. The questionnaire contained sections on demographics, perceptions of organ allocation and acceptance, LTI kidneys, and educational preferences. Descriptive analysis was performed.
Results: Two hundred fifty-one responses were analyzed, including patients (63%, n = 159), and caregivers (37%, n = 92), from 11 provinces and territories. Three-quarters (74%, n = 186) understood how patients are placed on the waiting list, and 65% (n = 162) understood how donor kidneys are allocated, but 72% (n = 181) and 68% (n = 171) wanted more information about the waitlist and donor kidney allocation criteria, respectively. Approximately 20% felt that the waitlist and allocation processes were not transparent. Awareness about the option to refuse a deceased donor kidney offer was high (69%, n = 174), yet nearly half of respondents (46%, n = 115) expressed concern about being disadvantaged if an offer for a deceased donor kidney was refused. One-third of participants (33%, n = 83) were open to accepting an LTI kidney.
Limitations: Compared to the general population, more study participants were white, and the majority were educated and financially at ease. This limits the generalizability of the results.
Conclusion: Enhanced communication is required to improve transparency and information about the allocation system and waitlist in Canada.
Introduction: Tracking the evaluation process of living kidney donor candidates facilitates benchmarking and can inform process redesign to improve experiences with the evaluation and enable more living donor kidney transplantation.
Methods: We reviewed the medical records for all living donor candidates who were actively undergoing evaluation at any time between January 1, 2013, and December 31, 2016, at the London Health Sciences Centre in London, Ontario, Canada. We abstracted information on demographic factors, the evaluation process, reasons for a delayed evaluation, reasons for an evaluation termination (eg, donation, decline, withdrawal, loss to follow-up), frequency and timing of evaluation testing, and recipient dialysis status.
Results: Over time, the number of living donor kidney transplants increased from 22 in 2013 to 32 in 2016 (18% and 34% of which were pre-emptive, respectively). The median number of candidates coming forward doubled from 167 in 2013 (2 candidates per recipient) to 348 in 2016 (4 candidates per recipient). Median time from first contact until donation decreased from 12.8 months in 2013 to 7.1 months in 2016 (a 45% reduction). The time from computed tomography (CT) angiography until donation (n = 74) was a median of 75 (interquartile range [IQR] = 36, 180) days, the longest single step in the evaluation. Common reasons for delay included waiting for the referral of their intended recipient for transplant evaluation (11% of candidates) and a need for the donor candidate to lose weight (8% of candidates). Donors completed the main evaluation tests on a median of 5 different dates. Thirty-six recipients started dialysis after their living donor candidates' evaluation had been underway for at least 3 months.
Conclusion: Tracking the steps and reasons for an inefficient living kidney donor evaluation process can be used for quality improvement, and efficiency improvements are expected to translate into improved outcomes and experiences.
Background: Some men who donate a kidney have reported testicular pain after donation; however, attribution to donation is not clear as no prior studies included a comparison group of nondonors.
Objective: To examine the proportion of male donors who reported testicular pain in the years after nephrectomy compared to male nondonors with similar baseline health characteristics.
Design participants and setting: We enrolled 1042 living kidney donors (351 male) before nephrectomy from 17 transplant centers (12 in Canada and 5 in Australia) from 2004 to 2014. A concurrent sample of 396 nondonors (126 male) was enrolled. Follow-up occurred until November 2021.
Measurements: Donors and nondonors completed the same schedule of measurements at baseline (before nephrectomy) and follow-up. During follow-up, participants completed a questionnaire asking whether they had experienced new pain in their eyes, hands, or testicles; those who experienced pain were asked to indicate on which side of the body the pain occurred (left or right). The pain questionnaire was completed by 290 of 351 male donors (83%) and 97 of 126 male nondonors (77%) a median of 3 years after baseline (interquartile range = 2-6).
Methods: Inverse probability of treatment weighting on a propensity score was used to balance donors and nondonors on baseline characteristics. After weighting, the nondonor sample increased to a pseudo sample of 295, and most baseline characteristics were similar between donors and nondonors.
Results: At baseline, donors (n = 290) were a mean age of 49 years; 83% were employed, and 80% were married; 246 (84.8%) underwent laparoscopic surgery and 44 (15.2%) open surgery; 253 (87.2%) had a left-sided nephrectomy and 37 (12.8%) a right-sided nephrectomy. In the weighted analysis, the risk of testicular pain was significantly greater among donors than nondonors: 51/290 (17.6%) vs 7/295 (2.3%); weighted risk ratio, 7.8 (95% confidence interval [CI] = 2.7 to 22.8). Donors and nondonors did not differ statistically in terms of self-reported eye pain or hand pain. Among donors, the occurrence of testicular pain was most often unilateral (92.2%) and on the same side as the nephrectomy (90.2%). Testicular pain occurred more often in donors who had laparoscopic vs open surgery: 48/246 (19.5%) vs 3/44 (6.8%) but was similar in those who had a left-sided vs right-sided nephrectomy: 44/253 (17.4%) vs 7/37 (18.9%).
Limitations: Participants recalled their symptoms several years after baseline, and we did not assess the timing, severity, or duration of pain or any treatments received for the pain.
Conclusion: Unilateral testicular pain on the same side of a nephrectomy is a potential complication of living kidney donation that warrants further investigation.
Background: Quality indicators are required to identify gaps in care and to improve equitable access to kidney transplants. Referral to a transplant center for an evaluation is the first step toward receiving a kidney transplant, yet widespread reporting on this metric is lacking.
Objective: The objective was to use administrative health care databases to examine multiple ways to define referral for a kidney transplant evaluation by varying clinical inclusion criteria, definitions for end of follow-up, and statistical methodologies.
Design: This is a population-based cohort study.
Setting: This study linked administrative health care databases in Ontario, Canada.
Patients: Adults from Ontario, Canada, with advanced chronic kidney disease (CKD) between April 1, 2017, and March 31, 2018.
Measurements: The primary outcome was the 1-year cumulative incidence of kidney transplant referral.
Methods: We created several patient cohort definitions, varying patient transplant eligibility by health status (eg, whether patients had a recorded contraindication to transplant). We presented results by advanced CKD status (ie, patients approaching the need for dialysis vs receiving maintenance dialysis) and by method of cohort entry (ie, incident only vs prevalent and incident patients combined), resulting in 12 unique cohorts.
Results: Sample size varied substantially from 414 to 4128 depending on the patient cohort definition, with the largest reduction in cohort size occurring when we restricted to a "healthy" (eg, no evidence of cardiovascular disease) group of patients. The 1-year cumulative incidence of transplant referral varied widely across cohorts. For example, in the incident maintenance dialysis population, the cumulative incidence varied more than 2-fold from 16.3% (95% confidence interval [CI] = 15.0%-17.7%) using our most inclusive cohort definition to 40.0% (95% CI = 36.0%-44.5%) using our most restrictive "healthy" cohort of patients.
Limitations: Administrative data may have misclassified individuals' eligibility for kidney transplant.
Conclusions: These results can be used by jurisdictions to measure transplant referral, a necessary step in kidney transplantation that is not equitable for all patients. Adoption of these indicators should drive quality improvement efforts that increase the number of patients referred for transplantation and ensure equitable access for all patient groups.
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