Canadian Journal of Kidney Health and Disease最新文献

Background: Antibody-mediated rejection (AMR) is an important cause of kidney transplant loss. A new strategy requiring application of precision medicine tools in transplantation considers molecular compatibility between donors and recipients and holds the promise of improved immunologic risk, preventing rejection and premature graft loss.

Objective: The objective of this study was to gather patients' and caregivers' perspectives on molecular compatibility in kidney transplantation.

Design: Individual semi-structured interviews.

Setting: The Centre hospitalier de l'Université de Montréal (CHUM) and McGill University Health Centre (MUHC) kidney transplant programs.

Participants: Kidney transplant candidates, kidney transplant recipients, and caregivers.

Methods: Twenty-seven participants took part in semi-structured interviews between July 2020 and November 2021. The interviews were digitally recorded, transcribed, and analyzed using the qualitative description approach.

Results: Participants had different levels of knowledge about the kidney allocation process. They expressed trust in the system and healthcare professionals. They indicated that a fair organ allocation system should strive to maximize graft survival as it would decrease the demand for deceased donor kidneys and allow more patients to access transplantation. Molecular matching and precision medicine were seen as important improvements in the kidney transplant allocation process given their potential to improve graft survival and decrease the need for retransplantation. However, participants were concerned about increased waiting times that may negatively impact some patients upon implementation of molecular matching. To address these concerns, participants suggested integrating safeguards in the form of maximum waiting time for molecularly matched kidneys.

Limitations: This study was conducted in the province of Quebec most of the participants were white and highly educated. Consequently, the results could not be generalizable to other populations, including ethnic minorities.

Conclusions: Molecular matching and precision medicine are viewed as promising technologies for decreasing the incidence of AMR and improving graft survival. However, further studies are needed to determine how to ethically integrate this technology into the kidney allocation scheme.

Trial registration: Not registered.

Purpose of review: Quality improvement (QI) initiatives use a team-based approach to problem-solving clinical and health system issues. All QI initiatives require the coordinated efforts of health care professionals and other stakeholders to encourage the provision of evidence-based clinical care. Most clinicians understand the principles of QI but may lack the training necessary to undertake individual projects.

Methods: An educational, nephrology-oriented clinical case was created based on the IDEAL study on timing of dialysis initiation, a prioritized quality indicator in several provinces. The case illustrates how to utilize commonly employed QI methodology and to provide a pragmatic framework for both developing and running a QI project. Core concepts addressed in this review include how to perform a QI chart audit, identification of a quality-of-care problem, engaging stakeholders, and how to conduct a root cause analysis that leads to selection of QI measures and change solutions. Last, plan-do-study-act (PDSA) cycles and interpretation of data using run charts are highlighted.

Sources of information: PubMed and Google scholar were used as sources of published QI methodology.

Key findings: This nephrology-oriented QI case highlights how a core set of QI principles and tools can be used to improve clinical care. This review demonstrates that determining clear goals, utilizing evidence-based guidance to improve timing of dialysis initiation, engaging the appropriate stakeholders, identifying a feasible and measurable change, and tracking if that change leads to improvement are essential components of all QI initiatives. The above framework can be utilized in a variety of clinical areas both within and beyond nephrology-specific care.

Limitations: Considerations regarding QI-specific data analysis were not addressed as they were beyond the scope of this review.

Early identification of kidney disease can protect kidney health, prevent kidney disease progression and related complications, reduce cardiovascular disease risk, and decrease mortality. We must ask "Are your kidneys ok?" using serum creatinine to estimate kidney function and urine albumin to assess for kidney and endothelial damage. Evaluation for causes and risk factors for chronic kidney disease (CKD) includes testing for diabetes and measurement of blood pressure and body mass index (BMI). This World Kidney Day, we assert that case-finding in high-risk populations, or even population-level screening, can decrease the burden of kidney disease globally. Early-stage CKD is asymptomatic and simple to test for and recent paradigm-shifting CKD treatments such as sodium glucose co-transporter-2 inhibitors dramatically improve outcomes and favor the cost-benefit analysis for screening or case-finding programs. Despite this, numerous barriers exist, including resource allocation, healthcare funding, healthcare infrastructure, and healthcare-professional and population awareness of kidney disease. Coordinated efforts by major kidney non-governmental organizations to prioritize the kidney health agenda for governments and aligning early detection efforts with other current programs will maximize efficiencies.

Anti-thymocyte globulin (ATG) is often used when delayed graft function (DGF) occurs post-transplantation. The ATG may be associated with an increased risk of infections but may also decrease rejection risk in high-immunological risk recipients. The safety of ATG for the indication of DGF in low-immunological risk recipients has not been well characterized. We conducted a retrospective cohort study of deceased donor kidney transplant recipients deemed low-immunological risk and not planned for ATG induction, from June 2019 to June 2023 (N = 139). Participants switched to ATG post-transplant due to DGF (exposure; N = 68) were compared to those who did not receive ATG for induction (controls; N = 71 basiliximab only induction). Outcomes examined included BK, cytomegalovirus (CMV), and serious infection as well as acute rejection, graft loss, and death. Participants who received ATG for DGF, compared to controls, were older (63.9 vs 59.7 years), more often had diabetes as cause of kidney failure (45.5% vs 33.8%) were more often recipients of death determination by circulatory criteria donor (70.5% vs 30.9%) and extended criteria donor kidneys (48.5% vs 32.3%). There was no significant difference in the probability of BK (22.1% vs 21.1%, P = .89), CMV (20.6% vs 9.9%, P = .08), serious infections (44.1% vs 43.6%, P = .96), acute rejection, graft loss, or death. The use of ATG for DGF following kidney transplantation did not significantly increase infection risk nor did it improve graft outcomes. Further studies are needed to clarify the risk-benefit trade-off of using ATG for DGF.

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.