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Initiating Maintenance Dialysis Before Living Kidney Donor Transplantation When a Donor Candidate Evaluation Is Well Underway

Habbous, Steven, MSc1; McArthur, Eric, MSc2; Dixon, Stephanie N., PhD1,2; McKenzie, Susan, MA3,4; Garcia-Ochoa, Carlos, MD1; Lam, Ngan N., MD, MSc5; Lentine, Krista L., MD, PhD6; Dipchand, Christine, MSc, MD7; Litchfield, Kenneth, MA3; Begen, Mehmet A., MSc, PhD1,8; Sarma, Sisira, PhD1; Garg, Amit X., MD, PhD1,2,9

doi: 10.1097/TP.0000000000002159
Original Clinical Science—General

Background Preemptive kidney transplants result in better outcomes and patient experiences than transplantation after dialysis onset. It is unknown how often a person initiates maintenance dialysis before living kidney donor transplantation when their donor candidate evaluation is well underway.

Methods Using healthcare databases, we retrospectively studied 478 living donor kidney transplants from 2004 to 2014 across 5 transplant centers in Ontario, Canada, where the recipients were not receiving dialysis when their donor’s evaluation was well underway. We also explored some factors associated with a higher likelihood of dialysis initiation before transplant.

Results A total of 167 (35%) of 478 persons with kidney failure initiated dialysis in a median of 9.7 months (25th-75th percentile, 5.4-18.7 months) after their donor candidate began their evaluation and received dialysis for a median of 8.8 months (3.6-16.9 months) before kidney transplantation. The total cohort’s dialysis cost was CAD $8.1 million, and 44 (26%) of 167 recipients initiated their dialysis urgently in hospital. The median total donor evaluation time (time from evaluation start to donation) was 10.6 months (6.4-21.6 months) for preemptive transplants and 22.4 months (13.1-38.7 months) for donors whose recipients started dialysis before transplant. Recipients were more likely to start dialysis if their donor was female, nonwhite, lived in a lower-income neighborhood, and if the transplant center received the recipient referral later.

Conclusion One third of persons initiated dialysis before receiving their living kidney donor transplant, despite their donor’s evaluation being well underway. Future studies should consider whether some of these events can be prevented by addressing inappropriate delays to improve patient outcomes and reduce healthcare costs.

This analysis using healthcare databases from 5 transplant centers in Canada confirms the difficulties in performing preemptive kidney transplants even with expedited living donor evaluation. Yet, not all the factors accounting for this observation can be promptly optimized.

1 Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada.

2 Institute for Clinical Evaluative Sciences, Kidney, Dialysis & Transplantation, Ontario, Canada.

3 Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease (CAN-SOLVE CKD) Patient Council, Canada.

4 Kidney Foundation of Canada, Montreal, Quebec, Canada.

5 University of Alberta, Edmonton, Division of Nephrology, Alberta, Canada.

6 Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, MO.

7 Queen Elizabeth II Health Sciences Centre, Halifax, Division of Nephrology, Nova Scotia, Canada.

8 Ivey School of Business, Western University, London, Ontario, Canada.

9 Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada.

Received 17 October 2017. Revision received 8 December 2017.

Accepted 22 December 2017.

Funding for this analysis was provided by Ontario’s Trillium Gift of Life Network. Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease (CAN-SOLVE CKD) is a patient-orientated research network to transform the care of people affected by kidney disease. It is led by Drs. Adeera Levin and Braden Manns. Patient partnerships in this project were supported by CAN-SOLVE. S.H. is supported by the Canadian Institutes of Health Research Frederick Banting and Charles Best Canada Doctoral Scholarship (reference number: GSD 140313). Dr. Ngan N. Lam was supported by a Kidney Research Scientist Core Education and National Training Program (KRESCENT) New Investigator Award. A.G. is supported by the Dr. Adam Linton Chair in Kidney Health Analytics, and a Canadian Institutes of Health Research Clinician Investigator Award.

A.G. received partnership funding from Astellas for a research grant funded by the Canadian Institutes of Health Research. The other authors declare no conflicts of interest.

The Institute for Clinical Evaluative Sciences (ICES) is a nonprofit research corporation funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC). The MOHLTC provided large administrative data sets to which the Trillium Gift of Life Network data were linked. Parts of this material are based on data and information compiled and provided by CIHI. The study was conducted at the ICES Western facility, which receives financial support from the Academic Medical Organization of Southwestern Ontario, the Schulich School of Medicine and Dentistry at Western University, the Lawson Health Research Institute and multiple clinical Departments. The study was conducted through the ICES Kidney, Dialysis and Transplantation (KDT) Research Program, which receives programmatic support from the Canadian Institutes of Health Research.

The study design and conduct, opinions, results and conclusions reported in this paper are those of the authors and are independent of the funding sources. No endorsement by ICES, CIHI, or the MOHLTC is intended or should be inferred. Amit Garg was supported by the Dr. Adam Linton Chair in Kidney Health Analytics and a Canadian Institutes of Health Research Clinician Investigator Salary Award. Graduate students who worked on this project were provided space in the Lilibeth Caberto Kidney Clinical Research Unit.

S.H., E.M., S.N.D., S.M., C.G.-O., N.N.L., K.L.L., C.D., K.L., M.A.B., S.S., A.X.G. participated in research design. S.H., E.M., S.N.D., S.M., C.G.-O., N.N.L., K.L.L., C.D., K.L., M.A.B., S.S., A.X.G. participated in the writing of the article. S.H., E.M., S.N.D., S.M., C.G.-O., S.S., A.X.G. participated in the performance of the research. S.H., E.M., S.N.D., C.G.-O., S.S., A.X.G. participated in data analysis.

Correspondence: Amit X. Garg, MD, PhD, Institute for Clinical Evaluative Sciences Western facility (ICES Western) Victoria Hospital, Room ELL-215, 800 Commissioners Rd, Victoria Hospital, London, Ontario, Canada N6A 5W9. (amit.garg@lhsc.on.ca).

Supplemental digital content (SDC) is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (www.transplantjournal.com).

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