Are Your Patients Well Prepared for Kidney Transplant?

Transcription

1 Are Your Patients Well Prepared for Kidney Transplant? Venkatesh Kumar Ariyamuthu MD FASN Disclosures National Kidney Foundation Scientific Advisory Board 78 year old Hispanic female ESRD secondary to DM HD since 2014 LUE AVF. Listed at another NM transplant center. CAD PCI in April 2018 On Plavix. BMI 30. HLA Antibodies mildly sensitized. 1

2 She has some questions My age does it matter (with regards to candidacy). Is there still a benefit with transplant? During the time of offer My donor used drugs. What is my risk? Kidney offer high KDPI. What to tell her? Overview Disease Burden, benefits of Kidney Transplant (KTx) and USRDS Data. Overview of the evaluation process. KAS changes since implementation. Barriers. Obesity, Frailty ODD increase/hcv transplants. Overview Disease Burden, benefits of Kidney Transplant (KTx) and USRDS Data. Overview of the evaluation process. KAS changes since implementation. Barriers. Obesity, Frailty ODD increase/hcv transplants. 2

3 Kidney Disease Burden 850 million people worldwide with kidney disease. Chronic kidney disease (CKD) 2.4 million deaths per year 6th fastest growing cause of death. ESRD 700,000 patients with ESRD in US. only 13 % are waitlisted for transplantation. < 20% get transplanted each year. Waiting List as of March 10, saw a decrease in KT waitlist for 2 years in a row ( < 100,000) 21,167 total kidney transplants living donor transplants. Geographic distribution of unadjusted transplant rate by state,

4 Median waiting time for KT, Percent of patients transplanted (living or DD) within one year of wait listing, Number of KT by donor type, Number of patients wait listed for KT, , 5, & 10 year Living Donor KT graft survival, , 5, & 10 year Deceased Donor KT graft survival,

5 1, 5, & 10 year Living Donor KT patient survival, , 5, & 10 year Deceased Donor KT patient survival, Survival Benefits JAMA Surgery March 2015 Volume 150, Number year adjusted survival across RRT modalities HD PD DD Tx LD Tx

6 13% of waitlisted KT candidates in the US have had ESRD for >11 years. RR of death in n=2329 KT recipients compared with patients on dialysis who had equal lengths of follow up from their 10 year dialysis anniversary was 0.60 Similar benefit for obese, HCV infected patients compared to remaining on dialysis. Caren Rose et al. CJASN 2017;12: Overview Disease Burden, benefits of Kidney Transplant (KTx) and USRDS Data. Overview of the evaluation process. KAS changes since implementation. Barriers. Obesity, Frailty ODD increase/hcv transplants. Kidney International (2012) 83,

7 Transplant Evaluation Team Physician (immunological, CVD, recurrent disease, other comorbidities)? Surgeon (Obesity/vascular targets/room in PKD) SW (psychosocial situation) Dietitian if needed (malnourished under or obesity) Pharmacist (medication counselling and education) Nurse Coordinator Waitlist NC. Thorough H and P Etiology/biopsy/dialysis duration/intradialytic hypotension/midodrine use. Prior h/o DVT/Lupus patients alkylating/b cell depletion exposure. Angina/angina equivalents/claudication pain. Sensitizing events. Frailty assessment (hospitalizations/ftt) 6 min walk Montreal Cognitive assessment. TUG test Initial Evaluation 7

8 Referral to a transplant center is an essential first step, however, referral does not equate to wait listing. Reducing Disparities in Access to Kidney Transplantation(RADIANT) Community Study collected patient referral data from all Georgia transplant centers. Center Level Variations in Transplant Referrals JAMA August 11, 2015 Volume 314, Number 6 Kidney Allocation Dec Make better use of available kidneys (Longevity matching). KDPI (donor quality)/epts(recipient survival odds) Increase transplant opportunities for difficult to match patients (increased equity). High cpra candidates 202 points for 100% cpra Increase fairness by awarding waiting time points based on dialysis start date. Have minimal impact on most candidates 8

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10 Kidney Allocation Change Dec

11 Overview Disease Burden, benefits of Kidney Transplant (KTx) and USRDS Data. Overview of the evaluation process. KAS changes since implementation. Barriers. Obesity, Frailty ODD increase/hcv transplants. Reduced access to kidney transplantation for AAs Patient preferences. Less likely to complete a KT evaluation. Low rates of deceased and living kidney donation. Patient Factors. Poor patient education. Low socioeconomic status (SES). Inadequate health insurance. More frequent contraindications. Medically, the severity of illness, incidence of diabetes, obesity, and comorbidities are higher. Immunologic factors. Clinician biases. Am J Nephrol 2017;46: Frailty and KTx Frailty, a measure of physiologic reserves an important risk factor transplant recipients. Shrinking (self report of unintentional weight loss of more than 10 lbs in the past year based on dry weight. Weakness (grip strength below an established cutoff based on gender and BMI). Exhaustion (self report). low activity (kcals/week below an established cutoff). Slowed walking speed (6 min walk or TUG test) Associations Post operative complications (2* increased risk) Length of stay Discharge to a skilled or assistedliving Mortality 94% increased risk of DGF 61% increased risk of early hospital readmission 11

12 Obesity KTx By 2030, > 50% of the U.S. population will be obese (BMI>30 kg/m2). BMI Is an Imperfect Measure of Adiposity. Reverse epidemiology (limited to patients with higher muscle mass). 60% at the time of KTx are obese (BMI>30kg/m2). DGF, wound complications, prolonged hospitalization, new onset diabetes mellitus, acute biopsy proven rejection and reduced graft survival. BMI of kg/m2 cut off Better survival than being on dialysis Am J Nephrol 2012;36: Advantages of LDRT Shorter wait times. Shorter cold ischemia times.? Better HLA compatibility. Likely to be higher quality donors than DDRT Incompatible Donation Blood type incompatible donation Transplant candidate receives a kidney from a living donor with a non matching blood type. Candidates receive specialized medical treatment before and after the transplant, may include splenectomy. Positive crossmatch donation Candidate has certain antibodies (a protein substance) that will immediately react against the donor s cells and cause the transplant to fail. This type of donation is usually only considered when no other living donors match. 12

13 Paired Kidney Donation (PKD) Number and Percent of PKD of all LD Kx, Overview Disease Burden, benefits of Kidney Transplant (KTx) and USRDS Data. Overview of the evaluation process. KAS changes since implementation. Barriers. Obesity, Frailty ODD increase/hcv transplants. 13

14 Opioid Epidemic & SOT Durand CM, Bowring MG, Thomas AG. Ann Intern Med May 15;168(10): Adult Increased Risk Donor (IRD) 2013 PHS Guidelines People who have had sex with a person known or suspected to have HIV, HBV, or HCV infections in the preceding 12 months MSM in the preceding 12 months Women who have had sex with a man with a history of MSM behavior in the preceding 12 months People who have had sex in exchange for money or drugs in the preceding 12 months People who have had sex with a person who had sex in exchange for money or drugs in the preceding 12 months People who have injected drugs by IV, IM, or subq route for nonmedical reasons in the preceding 12 months People who have had sex with a person that has injected drugs by IV, IM, or subq route for nonmedical reasons in the preceding 12 months People who have been in lockup, jail, prison, or a juvenile correctional facility for 72 hours in the preceding 12 months People who have been newly diagnosed with or have been treated for syphilis, gonorrhea, Chlamydia, or genital ulcers in the preceding 12 months People who have been on hemodialysis in the preceding 12 months (RISK FOR HCV ONLY) Any evidence of hemodilution NOTA precludes the use of HIV+ donors now waived for research due to HOPE Act Adapted from: Seem DL et al. Public Health Rep 2013; 128 (4): Number of Deceased Donors Recovered by Year and PHS IRD, Proportion of Deceased Donors With a History of IV Drug Use and Death Due to Drug Overdose During 2008 and 2018, by Region. 14

15 Residual risk of HIV and Hepatitis C Transmission from an IRD HIV Hepatitis C Intravenous drug abuser 1 in in 264 Men who have sex with males 1 in in 2632 Prostitutes 1 in in 870 Partner with the above 1 in in 741 Incarceration 1 in 16,667 1 in 1370 Kucirka LM, Sarathy H, Govindan P, et al. Risk of window period HIV infection in high infectious risk donors: systematic review and meta-analysis. Am J Transplant Jun;11(6): Kucirka LM, Sarathy H, Govindan P, et al. Risk of window period hepatitis-c infection in high infectious risk donors: systematic review and meta-analysis. Am J Transplant Jun;11(6): Comparative Risk Event Per 10,000 Mortality without liver transplant in next 3 months MELD ,000 Mortality in the Heart Transplant Waitlist 1A in next 12 months 1,640 Mortality in the Lung Transplant Waitlist in the next 12 months 1,260 Mortality on Kidney Transplant Waitlist in next 12 months 900 Mortality in the Heart Transplant Waitlist 1B in next 12 months 450 Lifetime risk of dying in a car accident 125 Risk of Acquiring HCV from Dialysis 37 Residual Risk of Acquiring HCV from an IVDA 32 Lifetime risk of dying crossing the street 16 Residual Risk of Acquiring HIV from an IVDA 5 Lifetime risk of dying in a place crash 2 Adapted from: Images created by Iconarray.com. Risk Science Center and Center for Bioethics and Social Sciences in Medicine, University of Michigan. Accessed August 12,

16 Turn down for What? Patient outcomes associated with declining IRD kidneys Bowring MG, Holscher CM, Zhou S, et al. Am J Transplant Mar;18(3): Survival Benefits with High KDPI kidneys UNOS data from 2003 to 2012 for adult DDKT. PS than 60 years for pre KT and non-pre KT KDPI greater than 85% transplants VS candidates remaining on the waitlist (including patients who received KDPI 0% to 85% transplants according to multivariate Cox regression models). Lower mortality after the first year compared with the waitlist including KDPI 0% to 85% transplants in patients older than 60 years. Transplantation Apr;101(4): Take home messages Refer patients early for Transplant. Completion of transplant evaluation process and ensure listing. PHS IRD donors 1/5 donors have them discuss with you or their transplant team. HCV Changing landscape may increase donor pool. 16

17 Thank You 17