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

Understanding Kidney Donors’ Increased Kidney Failure Risk

By now, we’ve all seen the studies stating that living kidney donors have an 8-11x increased risk of kidney failure as compared to their well-matched, two-kidneyed cohort. And you’ve probably seen the transplant industry’s spin on that data, their sputtering “Well, but, the *absolute* risk is still really, really low”

But is it?

Steiner attempts to answer that question, at least some of it, by breaking down the overall risk into its important pieces-parts. He says:

 

“The 1% lifetime post-donation risk in the US study requires medical screening to predict ESRD in 96 of 100 candidates. This is particularly unlikely in the 30–35% of candidates under age 35, half of whose lifetime ESRD will occur after age 64. Many experts have attributed the increased relative risks in these studies to loss of GFR at donation, which ultimately means that high–normal pre-donation GFRs will reduce absolute post-donation risks.”

“Young vs. older age, low vs. high–normal pre-donation GFRs, black race, and an increased relative risk of donation all predict highly variable individual risks, not a single “low” or “1%” risk as these studies suggest.”

A uniform, ethically defensible donor selection protocol would accept older donors with many minor medical abnormalities but protect from donation many currently acceptable younger, black, and/or low GFR candidates.

I encourage everyone to read the whole thing. Your health may depend on it.

 

 

Steiner, R. (2016). Moving closer to understanding the risks of living kidney donation Clinical Transplantation, 30 (1), 10-16 DOI: 10.1111/ctr.12652

Categories
OPTN Transplant Wait List

Transplant Wait List Watch 2016 #3

OPTN 8-11-2016As of 10:31 am on August 11, 2016, OPTN says there are 77,358 folks on the active US transplant wait list.

That’s a .33% decrease since May 10, 2016, and a 6.95% increase since this project began on April 19, 2011.

 

<- By using the larger statistic, OPTN, the government and the media are inflating the true wait list by 35.53%! 

 

Today, there are 107,290 kidney wait list registrations (active & inactive) and 99,387 candidates for a total of 7903 multiple listings (folks registered at more than one transplant center).*

 

May 10, 2016: 108,046 registrants and 100,102 candidates for 7944 multiple listings.

September 21, 2014108,989 kidney wait list registrations and 101,244 candidates, for 7745 multiple listings.

 

Kidney wait list registrants have decreased 1.55% since September 21, 2014. .

Kidney wait list candidates have decreased 1.83% since  September 21, 2014.

 

14.424 kidney wait list registrants have undergone at least one prior transplant. 13.44% of registrants.

13,109 kidney wait list candidates have undergone at least one prior transplant. 13.19% of candidates.

 

May 10, 2016: 14,601 kidney wait list registrants have undergone at least one prior transplant (compared with 16,054 on 9-21-2014. 14.7%) – 13.5%

13,252 kidney wait list candidates have undergone at least one prior transplant (compared with 14,493 on 9-21-2014. 14.3%) – 13.2%

 

Prior check-ins:

May 10, 2016: 77,617
March 18, 2016: 78,104
October 19, 2015: 79,052
August 23, 2011: 72,318
July 19, 2015: 78,296
May 19, 2015: 79,134.
April 9, 2015: 78,196
March 10, 2015: 78,012.
December 26, 2014: 79,870.
September 21, 2014: 79,127.
March 18, 2013: 74, 758.
January 20, 2013: 74,352.
November 9, 2012: 74,558
August 11, 2012: 73,104
June 24, 2012: 73,146
May 11, 2012: 73,141
January 30, 2012: 72,428
December 29, 2011: 72,656
November 28, 2011: 72,625
October 18, 2011: 72,642
Aug 4, 2011: 72,400
July 20, 2011: 72,345
July 10, 2011: 72,360
July 5, 2011: 72,319
May 23, 2011: 72,298
May 11, 2011: 72,244
April 29, 2011: 72,330

 

*Click on Data -> View Data Reports on OPTN’s menu. Then “National Data”. Category “wait list”. “overall by organ” Compare “Registrations” with “Candidates” to determine multiple listings.

 

**Back on that “National Data” screen. Choose “Organ by Previous Transplant”.

Categories
Living Donor Research Living Donor Risks Living Kidney Donor

How Many Living Kidney Donors Were Obese Pre-Donation?

47,705 adult living kidney donors as reported to OPTN from 1999 to 2011 were analyzed using their pre-donation BMI (body mass index)

  • 35.6% were normal weight.
  • 40.5% were overweight
  • 18.9% were mildly obese
  • 4.2% were moderate to morbidly obese
  • Overweight and mildly obese kidney donors have increased through time by 12% and 20% every 5 years, respectively
  • 63.6% of living kidney donors over the past thirteen years have spanned the overweight to obese categories

 

According to OPTN guidelines, having a BMI greater than 35 kg/m2 is considered a relative contraindication to be a living kidney donor. However, based on a 2007 survey, 20% of transplant centers surveyed excluded those with BMI greater than 40 kg/m2 , 52% excluded donors with BMI greater than 35 kg/m2 , 10% excluded those with BMI over 30 kg/m2 , 12% percent had no policy for exclusion, and 6% excluded based on BMI if they had other cardiovascular risks.

  • Short term outcomes of obese living kidney donors have shown increased wound related complications and longer operative times
  • At five year follow up, Kramer et al found that overweight and obese individuals had 20% and 40% risk of developing chronic kidney disease.
  • Having a higher baseline BMI can serve as an independent risk factor for end stage kidney disease.
  • The long term effects of obesity on the solitary kidney of a kidney donor are still uncertain. This risk factor increases the risk of developing other co-morbid conditions such as diabetes mellitus, hypertension, or even proteinuria which can together compromise the function of their solitary kidney
  • At a mean of 11 year follow up, obese donors had an increased risk of developing hypertension and dyslipidemia.

 

Read the entire article at the link (above). Take care of yourselves.

 
Sachdeva, M. (2015). Weight trends in United States living kidney donors: Analysis of the UNOS database World Journal of Transplantation, 5 (3) DOI: 10.5500/wjt.v5.i3.137

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!