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Living Donor Risks Living Kidney Donor

Anemia and Kidney Function

A living kidney donor recently asked me if there was a connection between kidney donation and anemia. Because I’m not a walking encyclopedia, I put my google-fu to work and learned a lot along the way.

An analysis of NHANES III found that a GFR <60 was associated with a lower hemoglobin level and a higher prevalence of anemia.

(Note:Hemoglobin is the part of the red blood cell that carries iron and helps transport oxygen throughout the body.)

“The prevalence of anemia was 1.8% among those with an estimated GFR of 90 or higher, compared with 5.2% among those with an estimated GFR between 30 and 59, and 44.1% among those with an estimated GFR between 15 and 29.”

“Non-Hispanic black persons had a lower mean hemoglobin level than non-Hispanic white persons. Older age, female sex, and elevated CRP [C-reactive protein] level were also significantly associated with lower hemoglobin levels.”

This article has multiple tables and figures; go check them out.

 

A study of 5222 folks diagnosed with chronic kidney disease but not yet on dialysis (meaning they have not yet progressed to end-stage renal disease) found a higher prevalence of anemia as GFR declines.

“Percentage of patients with hemoglobin less than or equal to 12 g/dL [the cut-off for an anemia diagnosis] increased from 26.7% to 75.5% when glomerular filtration rate decreased from greater than or equal to 60 to < 15.”

“Prevalence of hemoglobin less than or equal to 10 g/dL increased substantially from 5.2% to 27.2% when glomerular filtration rate diminished from 60 to < 15.”

“Anemia was present in 47.7% of 5222 predialysis patients with chronic kidney disease”

 

Nurko states that most people “with chronic kidney disease eventually become anemic”.

“Factors likely contributing to anemia in chronic kidney disease include blood loss, shortened red cell life span, vitamin deficiencies, the “uremic milieu,” erythropoietin (EPO) deficiency, iron deficiency, and inflammation.”

“Deficiency of erythropoietin is the primary cause of anemia in chronic renal failure, but it is not the only cause. A minimal workup is necessary to rule out iron deficiency and other cell-line abnormalities.”

Erythropoietin is a protein excreted by the kidneys (yet another thing potential living kidney donors aren’t told prior to donating) which promotes the formation of red blood cells by the bone marrow. The kidney cells responsible for making erythropoietin are sensitive to oxygen levels in the blood, releasing erythropoietin when they drop too low. Red blood cells, as well, carry oxygen.

“Researchers postulate that the specialized peritubular cells that produce EPO are partially or completely depleted or injured as renal disease progresses, so that EPO production is inappropriately low relative to the degree of anemia”

 

“The consensus is that untreated anemia contributes to the large cardiovascular disease burden in [the CKD} population.”

“Left ventricular hypertrophy is closely linked to chronic kidney disease. The estimated prevalence in stage 3 and 4 is 39%, and it is even higher in patients with lower renal function”

If iron supplements don’t correct the issue, this author recommends the addition of an erythropoiesis-stimulating agent (ESA). “Studies suggest that treating anemia with a goal of raising the hematocrit to at least 36% improves quality of life, decreases the need for transfusions, improves muscle strength and cognitive function, and decreases rates of hospitalization and death”

Take care of yourself!

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Living Donor Research Living Donor Risks Living Kidney Donor

Cardiovascular Changes Shown in Living Kidney Donors

It’s well established that a reduction in kidney function (GFR) significantly increases one’s risk of cardiovascular disease and death. It’s all known that folks in all stages of chronic kidney disease are at risk for heart troubles.

Finally, a few researchers got together and decided to look at how living kidney donor’s hearts change post-nephrectomy.

 

“We hypothesised that the reduction in GFR associated with nephrectomy causes increased left ventricular (LV) mass, impaired LV function and increased aortic stiffness.”

 

“Compared to controls, nephrectomy in donors was associated with increases in [left ventricular] mass ; [left ventricular] mass-volume ratio and [carotid-femoral pulse wave velocity] PWV ; and reductions in aortic distensibility [flexibiity; ie. more stiffness] and global circumferential strain”

 

“Change in GFR independently predicted the change in LV mass (R2=0.26; P<0.01).”

 

“Nephrectomy causes concentric LV remodelling and dysfunction, increased aortic stiffness and adverse changes in[cardiovascular]  CV biomarkers. These findings suggest reduced GFR is an independent causative CV risk factor and that donors should be under long-term CV review.”

 
Moody, W., Ferro, C., Edwards, N., Chue, C., Lin, E., Taylor, R., Cockwell, P., Steeds, R., & Townend, J. (2015). EFFECTS OF NEPHRECTOMY ON CARDIOVASCULAR STRUCTURE AND FUNCTION IN LIVING KIDNEY DONORS Journal of the American College of Cardiology, 65 (10) DOI: 10.1016/S0735-1097(15)62150-7

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Follow-Up Liver Donor Living Donor Research Living Donor Risks Living Kidney Donor

American Society of Transplant Surgeons Winter Symposium 2015 Abstracts

Read ’em all here folks: http://onlinelibrary.wiley.com/doi/10.1111/ajt.13164/pdf

 

Long-Term Living Donor Outcomes: When To Say No Dorry Segev (Pg. 43).

“The risks of donation are real. And serious. And attributable to donating. In other words, there are things that might happen to an individual if he donates that would not happen to that individual had he not donated”

And

“And of course it will only get worse. No doubt as we follow the new cohort of donors with more medical issues (higher BMI, higher blood pressure, etc.) for much longer periods of time (current follow-up in large studies is relatively still “short-term” or “medium-term”), we will discover much more risk that donors take.”

 

Note: We/They aren’t following anyone. There is no living donor registry; we don’t even have one-year of comprehensive living donor data.

***

Non-Academic Transplant Business Intelligence – A Surgeon’s Perspective Robert Osorio (pg 47).

” transplant professional societies now host career development seminars to improve business intelligence among their membership. The paucity of literature is also improving, and reviews are now available regarding the finances of transplantation”

and

“In 2008, ASTS launched the first comprehensive compensation study for transplant surgeons practicing within the United States4 . These results have provided a better understanding of total compensation, including salary and benefits, of academic staff surgeons, program directors, and academic transplant surgeons in leadership positions. This type of study is readily used in compensation agreements requiring fair market value (FMV) estimates of salary for non-academic transplant surgeons who are in an employed model”

***

Eliminating the Significant Regional Variation in Donor Conversion Rates Provides the Most Significant Reduction To Waitlist Mortality. (pg 49)

” Redistricting might reduce waitlist mortality and potentially saves 563 lives over 5 years. Here we examine national donor conversion rates and waitlist opportunities.”

***

Hypertension and Diabetes in Live Kidney Donors and Matched Nondonors (pg 55).

“Living donors had lower diabetes than matched controls immediately after donation, but higher incidence past 10 years. Living donors had substantially higher long-term risk of diabetes. Risk of hypertension increased more quickly over time for black donors than nonblack donors. Hypertension incidence did not differ between donors and controls.”

***

Patterns of Physician Visits Before and After Living Kidney Donation (pg 66)

“Smokers, donors with less than college education, and male donors (particularly single men) are less likely to visit a PCP annually after-donation, and may benefit from targeted efforts to improve PCP followup.”

***

Predonation Characteristics Associated With Risk of End-Stage Renal Disease in Live Kidney Donors (pg 70)

“Obese donors and those with a high blood pressure have signifi – cantly higher 15-year risk of ESRD compared with other donors.”

**

Outcomes After Right Kidney Living Donor Transplant Are Associated With Center Volume (pg 76)

“RKLDT [Right Kidney Living Donor Transplant] is associated with a higher rate of GF [Graft Failure} among centers performing <12 RKLDT annually, whereas there is a 2-fold reduction in the RR of GF among experienced centers ( >12 RKLDT /year).”

**

Analytic Morphomics Do Not Predict Long-Term Outcomes in Living Kidney Donors (pg 83)

“Survey results were obtained from 598 living kidney donors (response rate 57.6%). The mean follow-up time from donation was 9.1 years. “

And

” however, 17.0% of patients reported new diagnosis of at least one significant cardiovascular risk factor including: diabetes(2.5%), hypertension(14.0%), kidney disease(1.0%), heart attack(0.3%), and stroke(1.3%).”

 

Categories
Living Donor Research Living Donor Risks Living Kidney Donor

Heart Changes One Year Post-Kidney Donation

Unfortunately, I can’t get access to the entire article ($$$) so this is from the abstract.

38 living kidney donors were included in the study.

 

“The mean serum interleukin-6 levels, both at 3 months and 12 months, were significantly increased as compared to the baseline (P=0.007 and P<0.001, respectively).”

 

Interleukin-6 stimulates inflammatory and auto-immune responses. Elevated levels of Interleukin-6 have been found in folks with congestive heart failure, and may contribute to myocardial (heart) damage.

 

“The mean serum asymmetric dimethyl-arginine (P<0.001) and VCAM levels (P<0.001) at 12 months were significantly increased as compared to baseline.”

 

ADMA i a by-product of protein synthesis andfound in blood plasma. Raised levels of ADMA seem to be associated with cardiovascular disease. Specifically, ADMA plays a crucial role in vascular (blood vessel) tone and structure.

 

“FMD values at 1 year (9.3%+/-7.1%) were significantly decreased as compared to 3 months (13.0%+/-6.0%, P=0.001) and baseline (13.9%+/-6.3%, P=0.002).”

 

FMD = Flow-Mediated dilation. FMD is a way to measure how blood flows through, in this case, the brachial artery (upper arm). If the FMD drops, it can signal damage to the endothelium, the inner lining of the blood vessels.

 

“In multivariate analysis, serum uric acid (P=0.001), estimated glomerular filtration rate (P=0.027), and VCAM (P=0.014) levels were the independent predictors of FMD 12 months after kidney donation.”

 

VCAM = vascular cell adhesion molecule. Which is pretty much what it sounds like. It helps in maintaining the inner lining of the blood vessels (endothelium).

 

Conclusion: Our findings suggest that kidney donation might increase the cardiovascular risk in kidney donors.

 
Yilmaz BA, Caliskan Y, Yilmaz A, Ozkok A, Bilge AK, Deniz G, Sariyar M, & Yildiz A (2014). Cardiovascular-Renal Changes After Kidney Donation: One-Year Follow-Up Study. Transplantation PMID: 25226174

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Living Donor Risks

Losing a Whole Kidney vs. Part of One Matters

I’ll let the authors begin:

 

 It is clear  that Chronic Kidney Disease  (GFR <60mls/min) is associated with reduced  life  expectancy,  partly  due  to  an  increased  risk  of  cardiovascular  disease.

 

Are we clear? Reduced kidney function = increased risk of cardiovascular disease. Try to remember that when a member of the transplant industry tries to say that living kidney donors have no increased risk of heart disease.

 

Anyway, so these authors compared two groups: those who had a whole kidney removed, and those who only had part of a kidney removed.

 

16.7& of those who had a partial nephrectomy had a post-surgical GFR <60.

35.4% of the full nephrectomy group had GFR of <60.

Six months post-nephrectomy. (PS. GFR <60 is considered Stage 3 Chronic Kidney Disease.)

 

Their conclusion:

 

Smaller  reductions  of  GFR  after  partial  versus  total  unilateral nephrectomy  are  of  magnitudes  that  are  significant  for  overall  life  expectancy  in  large  cohorts

 

 

Stephen  KD  Hamilton , Grant  D  Stewart , Alan  McNeill , Antony CP  Riddick   , & Richard  Phelps  (2014). Renal Function After Unilateral Nephrectomy
Scottish Universities Medical Journal  , 3 (2), 22-31