KDIGO Clinical Practice Guidelines for the Care of the Kidney Transplant Recipient
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Transcript of KDIGO Clinical Practice Guidelines for the Care of the Kidney Transplant Recipient
Transplantation: What 2008 has in Store
Transplantation: What 2008 Has in Store
Gigi Politoski, SVP for ProgramsDawn Townsend, Director,
US Transplant games
Transplantation: What 2008 has in Store
KDIGO Clinical Practice Guidelines for the Care of the Kidney Transplant
Recipient
• Transplant recipients carry the burden of disease over to transplantation
• Transplant recipients still may have CKD based on their GFR
• Transplant recipients need to be managed based on their stage of CKD
Transplantation: What 2008 has in Store
KDIGO Clinical Practice Guidelines for the Care of the Kidney Transplant
Recipient
• Transplant Center/Surgeon may operate under “you’re fixed” and focus more on immunosuppressive therapy
• Community nephrologists knows how to manage, but don’t for fear immunosuppressive may be compromised
Who’s responsible for the care?
Transplantation: What 2008 has in Store
KDIGO Clinical Practice Guidelines for the Care of the Kidney Transplant
Recipient
• Immunosuppression• Graft monitoring and infection• Cardiovascular disease and risk factors• Malignancies and other considerations
Main Content Topics:
Transplantation: What 2008 has in Store
Immunosuppression
• Initial (Induction) Immunosuppression• Maintenance Immunosuppression• Monitoring • Acute Rejection
Transplantation: What 2008 has in Store
Graft Monitoring and Infection
• Treatment of Chronic Allograft Injury• Recurrent Kidney Disease• Monitoring of Kidney allograft Function• Vaccination and Treatment of Infectious
Diseases
Transplantation: What 2008 has in Store
Cardiovascular Risk
• Management of Hypertension and Dyslipidemias
• Diabetes• Obesity• Tobacco Use
Transplantation: What 2008 has in Store
Malignancies and Other Considerations
• Cancer of the Skin, Uterus/Cervix, Breast, Prostate, Colorectal, Hepatocellular, Kidney
• Bone Disease, Anemia• Pregnancy• Growth and Development in Children
Transplantation: What 2008 has in Store
KDIGO Clinical Practice Guidelines on Care of the Kidney Transplant
Recipient
• Public Review in June 2008• Published in December 2008• Implementation will begin December
2008/ January 2009
Timeline:
Transplantation: What 2008 has in Store
Kidney Allocation Review Policy (KARS)
• OPTN/UNOS is reviewing the allocation system for deceased donor kidneys
• NKF and other organizations, constituents asked to provide feedback during the policy development process
• Concept of “net survival benefit” or prediction of LYFT: Life Years From Transplant, increasing the number of extra “life years” gained by transplant
Transplantation: What 2008 has in Store
Kidney Allocation Review Policy (KARS)
• LYFT variables considered: age, time exposed to ESRD, BMI, diagnosis, previous transplant, other factors
• Disadvantages: LYFT varies greatly by age, diabetes• Advantages: LYFT is similarly distributed by race,
gender• Unknown: Impact on living donation? (Younger
patients who are more likely to have potential living donors will receive more of the available deceased donor kidneys?)
• A final policy proposal has NOT been finalized yet
Transplantation: What 2008 has in Store
Transplant Tourism and Payment for Organs
• The World Health Organization (WHO) estimates that organ trafficking accounts for 5-10% of kidney transplants worldwide
• Pakistan: at least 2,000 Pakistanis have donated kidneys to “transplant tourists”
• India: In poverty-stricken Chennai, 90 tsunami survivors have sold their kidneys but did not receive the payment promised to them. In Bangladesh, human kidneys, livers and corneas are for sale.
• India: An illegal kidney transplant racket recently uncovered. Hundreds of poor laborers forced or duped into donating to wealthy foreigners.
• Philippines: destination country for transplant tourists• Recipients from the Gulf Region, Asia and North America
Transplantation: What 2008 has in Store
Transplant Tourism and Payment for Organs
• China: The national government enacted legislation in 2007 which has reduced the rate of executions in China (and the organ transplant rate) substantially. Transplant tourists are now seeking other destinations.
• The World Health Assembly urges its member states to “take measures to protect the poorest and vulnerable groups from transplant tourism and the sale of tissues and organs, including attention to the wider problem of international trafficking in human tissues and organs”.
• NKF remains opposed to transplant tourism and payment for organs.
Transplantation: What 2008 has in Store
NKF Advice to Potential Donors and Transplant Candidates
• Potential non-directed living donors: work through a transplant center to be matched to an appropriate recipient (not try to find a recipient on their own).
• Transplant candidates are discouraged from traveling overseas for transplantation
• Dangers to both living donors and recipients (poor medical outcomes, infection or disease transmission, lack of follow-up care).
Transplantation: What 2008 has in Store
NKF Advice to Potential Donors and Transplant Candidates
• Most transplant candidates find a living donor among someone they already know– or someone in their community.
• The best strategy is to let the community (family, friends, acquaintances, co-workers, their religious community or social clubs) know about their need for a transplant and options available (living vs. deceased donor)
• See NKF’s “Suggested Process for Potential Non-Directed Living Donors” and “Waiting for a Transplant”
Transplantation: What 2008 has in Store
National Living Donor Assistance Center (NLDAC)
• Administered by the DoT through a cooperative agreement with the University of MI and the ASTS
• Mission is to reduce the financial disincentives to living donation
• Reimbursement for travel, hotels, meals, other non-medical expenses incurred by living donors/potential donors
• Priority is given to individuals not otherwise able to afford the expenses
Transplantation: What 2008 has in Store
National Living Donor Assistance Center (NLDAC)
• Provides up to $6,000 per donor• Transplant centers must register with NLDAC
and submit applications on behalf of potential donors
• 232 transplant centers have registered• NKF has been asked for input and
recommendations• Visit www.livingdonorassistance.org or call
703.414.1600
Transplantation: What 2008 has in Store
Paired exchange
Donor 1
Donor 2 Recipient 2
Recipient 1
NOT compatible
NOT compatible
OPTN/UNOS data (based on available data
as of 1-4-08):
260 paired exchanges have been completed in the U.S. (520 transplants)
60 U.S. transplant centers have performed paired exchanges
Transplantation: What 2008 has in Store
Emerging Trends in Kidney Exchange
• New websites & organizations being established to try to facilitate exchanges
• OPTN/UNOS involvement?
• Increasing numbers of 3-way, 4-way exchanges…
Optimization: a branch of mathematics that calculates which decisions will give the most benefit from a limited resource. This technology is already used in:
• Airline scheduling • Stock portfolio management • Mapping driving directions • Residency matching
Transplantation: What 2008 has in Store
Optimization In Paired Donation
The resource: is the pool of willing (but incompatible) donors.
The decision: Which incompatible pair should be matched with which other incompatible pair? Some pairs could be matched with many different pairs.
Optimization could mean hundreds more patients per year will receive a kidney.*
* www.optimizedmatch.com
Transplantation: What 2008 has in Store
Math meets medicine* Optimizing the match
Each number represents a recipient & his/her incompatible donor (40 incompatible pairs, numbered 0-39).
Each line indicates 2 pairs (4 people) who would be compatible for paired exchange.
* Math News, Vol 5, Issue 2
Transplantation: What 2008 has in Store
Math Meets Medicine: Optimizing the match
How do you decide which series of matches would yield the most transplants?
Example:
Pair 22 is compatible with Pair 38.
A paired exchange takes place between these 4 people (without considering all possible combinations first).
Transplantation: What 2008 has in Store
Math meets medicine Optimizing the match
Outcome:
Pair 22 and Pair 38 have been matched in a paired exchange.
But strategically, these pairs were the wrong choice for a match. Many of the matches (previously possible) have been lost.
A “bad match” can significantly affect opportunities for everyone else…
Transplantation: What 2008 has in Store
Optimizing Matching of 8 Pairs
Transplantation: What 2008 has in Store
Number of Transplants Versus Quality of The Match
4 matches - 50 points 3 matches - 60 points
Transplantation: What 2008 has in Store
Recipient 2Recipient 1
Non-directed donor
Donor 1
NOT compatible
Donor 3
Recipient 3
Donor 2
NOT compatible
NOT compatible
Chain continues
Never Ending Altruistic Donor Chain (NEAD): Utilizing Optimization
The last potential donor in the chain becomes a non-directed donor in a new chain.
Transplantation: What 2008 has in Store
Early and Pre-emptive Transplant:
Crucial to NKF’s Strategic Plan• Board of Directors Decision
• Professional and Patient Surveys
• Controversies Conference held (March 2007)
• Publication pending in (CJSAN 2008)
Transplantation: What 2008 has in Store
Nephrologist Survey ResultsPradel, Jain, Mullins, Vassalotti, Bartlett
• 5,911 nephrologists contacted • 476 or 8% responded • 71% believe that preemptive transplant is the
best• 26% believe that nephrologists should educate
CKD patients• 19% believe that pre-emptive transplant would
increase the demand for deceased kidney donors • 25% felt dialysis centers would lose revenue
referring preemptively• 47% agreed there is a need to develop practice
recommendations
Transplantation: What 2008 has in Store
Patient Survey
Purpose of Survey was to determine: • Why persons with CKD delay transplantation• What education they received about the transplantation option• How to educate patients about living donation and transplantation
Objectives of Study were to determine: • When and from whom do patients learn about transplant, living
donation and treatment options? • What barriers do patients face in pursuing early transplants?• What do patients fear about transplantation and living donation? • How does this impact high risk groups (African Americans, rural, re-
transplant)
Transplantation: What 2008 has in Store
Patient Survey Findings
• 518 responses (15% of random sample, IMIS)
• 76% (316) had kidney transplant• 24% (101) have CKD (no transplant) • 22% (92) are high risk
Transplantation: What 2008 has in Store
Patient Survey Findings (continued)
Patients Want to Learn More About:• How to work the system 76%• Information about donor 55%• Potential for returning to dialysis
42%• Finances, Medicare 41%• How to evaluate treatment options
37% • How long kidney will last 35%• Meds side effects 28%• Impact on Quality of Life 23% • Risks involved 20%
Patients Worry About:• Medical Costs 70%• Don’t want to ask for a
living donor 62%• Costs to living donor 61%• Health of living donor 56%• Affording medications 48%• Scared of surgery 40%• Don’t want people to know
I’m sick 36%• Needing to be on dialysis
before transplant 26%• Anti-rejection drugs 26%
Transplantation: What 2008 has in Store
Patient Survey Findings (continued)
• Almost half of respondents without a transplant never discussed this option.
• The discussion came too late for many who did discuss it.
• Doctors were not initiating this discussion and patients and were not the first to bring up the topic to patients (probability for misinformation from unreliable sources).
Transplantation: What 2008 has in Store
KDOQI Early Transplant Conference
March 2007 in Alexandria, VAChairs: Robert Gaston, Stephen BartlettParticipants: 60 nephrologists/surgeons
experts
Conference Recommendations (CJASN)
Transplantation: What 2008 has in Store
Topline Summary
Benefits: Barriers:• Less interruption to
employment and home
• Better outcomes: longevity and quality
• Avoid medical complications of dialysis
• Avoid costs associated with initiation of dialysis (vascular access)
• Medicare may not cover early evaluation or surgery
• Finding a living donor
• Being ready psychologically, financially, socially
• Access to doctors knowledgeable about the transplant option
Transplantation: What 2008 has in Store
Early Transplant Initiative
• Primary care MDs Lab reporting of eGFR Improved education regarding CKD and the benefits
of early referral for nephrology co-management • Nephrology
Develop multidisciplinary CKD clinic Coordinate evaluation with transplant centers to
facilitate efficient care Improve access for new referrals Develop strategies to expand nephrology manpower
• Collect and report nephrologists’ and dialysis units’ transplant referral rates
Recommendations to Address Physician Barriers to
Preemptive Transplantation:
Transplantation: What 2008 has in Store
Early Transplant Initiative
• Highlight transplantation in CKD management education
• Encourage multidisciplinary CKD care• Psychosocial support for patients and families during
the evaluation process• Public education- World Kidney Day• Support and resources for living donor expenses• Expanded insurance coverage for early transplant
evaluation and assessment
Recommendations to Address Patient Barriers to Preemptive Transplantation:
Transplantation: What 2008 has in Store
Early Transplantation Initiative
• Create an implementation plan• Seek collaboration with other interested
groups• Begin a dialog with transplantation
societies• Develop resources and pilot test
Next Steps