Categories
Informed Consent Living Donor Research Living Donor Risks Living Kidney Donor

Pre-Nephrectomy Kidney Volume Matters

Pre-nephrectomy (kidney removal) volume, otherwise known as parenchyma ,was measured in 75 patients who underwent the procedure from 2000-2010.
“Over median follow-up of 36 months postsurgery, progression to Chronic Kidney Disease (defined as GFR less than 60) occurred in 42.6% of patientsMedian time to reach CKD postnephrectomy is 12.7 (range 0.03–43.66) months for renal volume <144?mL but not achieved if renal volume is >144?mL.”

Normal kidney parenchymal volume and preoperative eGFR are independent predictive factors for postoperative CKD after Radical Nephrectomy and may represent renal reserve for both surgically and medically induced CKD, respectively.

Now, the reason I emphasized that last phrase is because too many folks try to say that a 60 GFR is okay in a living kidney donor (surgically induced) but not in a two-kidneyed person (aka medically induced). These researchers differ with that conclusion.

 

 

 

Wu, F., Tay, M., Tai, B., Chen, Z., Tan, L., Goh, B., Raman, L., & Tiong, H. (2015). Preoperative Renal Volume: A Surrogate Measure for Radical Nephrectomy-Induced Chronic Kidney Disease Journal of Endourology, 29 (12), 1406-1411 DOI: 10.1089/end.2015.0318

Categories
Deceased Organ Donation Organ Allocation

Older Kidneys Are A Good Alternative For Older Recipients

“[Deceased donor] organs from older donors are often discarded due to the macroscopic appearance of the parenchyma or major vessels. On the other hand, a large number of elderly patients are potential candidates for kidney transplantation, while many kidneys from elderly deceased donors are discarded due to a lack of age-matched recipients. In addition, a large number are often discarded due to the lack of compatible recipients among elderly patients undergoing chronic dialysis.”

“From 2007 to 2012, we performed a prospective observational study comparing 26 elderly patients receiving PKT with a control group of 26 elderly patients receiving a first transplant after prior dialysis.”

 

“Mean age of recipients was 74.3 ± 2.9 years and mean age of donors was 73.8 ± 4.1 years.”

 

“Death-censored graft survival was 96% in the PKT pre-emptive kidney group; prior to dialysis] group and 68% in the control group, at 5 years after transplantation. Immediate and delayed graft function occurred in 92% and 3.8%, respectively, of patients in the PKT group and 53% and 34.6% of patients in the control group . Acute rejection was significantly more frequent in PKT patients (23.1% vs 3.8%).

At the end of follow-up time 35.5 ± 20.1 months, the glomerular filtration rate GFR] was similar in both groups (42.2 ± 11.7 vs 41.7 ± 11.2 ml/min, p-value = 0.72). Patient survival was similar in the two groups.”

 

Morales, E., Gutiérrez, E., Hernández, A., Rojas-Rivera, J., Gonzalez, E., Hernández, E., Polanco, N., Praga, M., & Andrés, A. (2015). Preemptive kidney transplantation in elderly recipients with kidneys discarded of very old donors: A good alternative Nefrología (English Edition), 35 (3), 246-255 DOI: 10.1016/j.nefroe.2015.07.003

Categories
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!

Categories
Living Donor Research Living Donor Risks Living Kidney Donor

African-American Living Kidney Donors At Higher Kidney Risk

The authors examined a database linking U.S. registry identifiers for living kidney donors (1987-2007) to billing claims from a private health insurer (2000-2007 claims)

 

Among 4650 living donors, 13.1% were African American and 76.3% were white; 76.1% were first-degree relatives of their recipient. By 7 years post-donation, after adjustment for age and sex, greater proportions of African American compared with white donors had renal condition diagnoses: chronic kidney disease (12.6% vs 5.6%), proteinuria (5.7% vs 2.6%), nephrotic syndrome (1.3% vs 0.1%), and any renal condition (14.9% vs 9.0%).

 

Folks, this is only seven years post-donation. the average living kidney donor is 40/41; life expectancy is near 80. The long-term ramifications of these numbers are staggering and horrifying.

Please, everyone: take care of yourselves.

 
Lentine KL, Schnitzler MA, Garg AX, Xiao H, Axelrod D, Tuttle-Newhall JE, Brennan DC, & Segev DL (2015). Race, Relationship and Renal Diagnoses After Living Kidney Donation. Transplantation PMID: 25905980

Categories
Informed Consent Living Donor Research Living Donor Risks Living Kidney Donor

Living Kidney Donation’s Medical Risks Are Unknown, says Segev

Dr. Dorry Segev is a transplant surgeon and researcher at Johns Hopkins with many living kidney donation publications on his resume. At the American Society of Transplant Surgeons Winter Symposium 2015, he gave a presentation entitled “Long-Term Living Donor Outcomes; When to Say No“.

If you have an extra 20  minutes, I suggest sitting down and watching the video, which contains Segev’s audio and powerpoint slides. He discusses the study he authored in 2010, which has been dissected ad nauseum, and a more recent study he co-authored with Muzzale, which stated that living kidney donors have an 8-11x increased risk of end-stage renal disease as compared to their well-matched, two-kidneyed counterparts.

 

If you’re only interested in the good parts (aka the reason behind the blog post headline), confine yourself to the first minute and a half, wherein Segev says:

 

“We do about 6,000 of these a year, and we still have actually very little understanding of the medical risks.”

“The old school was we just told people, ‘Your risk of ESRD after donation is no higher than that of the general population.’ I mean that’s completely stupid.  That’s like basically saying, ‘Compared to obese, hypertensive, poor health behavior America, you won’t be that bad.  We don’t know how bad you’ll be, but don’t worry, it’s no higher than the general population.’  But we use this as sort of like this reassurance to donors.  I mean it’s completely scientifically stupid.”

“To quote the past ASTS past president Goran Klintmalm …’This is bullshit.'”

 

Can we please, pause for a minute and soak this in?

For 60 years, the transplant industry has been telling the public that living donation is safe, minimal risk, nothing to be concerned about, no danger here, etc. etc. etc. to infinity and beyond. They’ve separated us from other populations who have kidneys removed, claiming that we’re “different” because we’re “healthier”, and that even though people with isolated renal tumors should only undergo partial nephrectomies to preserve their nephrons, living donors are apparently some unique species with super-special nephrons that don’t need saving…..

It’s just so – ridiculous.

And now we have the first admission that it’s total bullshit.

 

Unlike the grandstanding that took place when Segev published his “living donors don’t die earlier” study in 2010 (which didn’t really say that, by the way; that’s just what the *media* claimed it said), this profound revelation won’t even be a blip on the media’s radar screen. Because who, outside of the transplant industry, pays attention to what’s said at these stuffy, boring conferences? Hell, half of the transplant industry probably skips it too.  While I wish I could say they’ll stop lying to potential kidney donors (and the media, and the public) and admit that yes, there is risk to donating, and no, we don’t know what that is, I know better. After all, this is the same industry that ignored repeated letters from the FDA about not using the Hemolock clip, which resulted in multiple living kidney donors deaths and injuries. Too many of them, too often, refuse to let facts get in the way of their opinion.

I guess we’ll have to do it for them. Bookmark this post. Anytime you see an article, or a post on a forum/group that perpetuates the myths, just send them this.

And let me know what happens.