Should You Accept What Others Reject? McDonald, Stephen P; Irish, Georgina L
Transplantation,
2023-Jun-01, 2023-06-00, 20230601, Volume:
107, Issue:
6
Journal Article
Background
Decisions about solid organ transplantation are complex. Patient decision aids (PDAs) enhance traditional education, by improving knowledge and supporting patients to align their values ...with treatments. There are increasing numbers of transplantation PDAs, however, it is unclear whether these are effective. We conducted a systematic review of studies assessing the impact of PDA use in transplantation.
Methods
We searched the Cochrane Register of Controlled Trials, CINAHL, EMBASE, MEDLINE, and PsycINFO databases from database inception to October 26, 2020. We included primary studies of solid organ transplantation PDAs defined by the International Patient Decision Aids Standards. All comparators and reported outcomes were included. Mean difference in knowledge (before vs. after) was standardized on a 100‐point scale. Pooled‐effect for PDAs was calculated and compared to the standard of care for randomized controlled trials (RCTs) and meta‐analyzed using random effects. Analysis of all other outcomes was limited due to heterogeneity (PROSPERO registration, CRD42020215940).
Results
Seven thousand four hundred and sixty‐three studies were screened, 163 underwent full‐text review, and 15 studies with 4278 participants were included. Nine studies were RCTs. Seven RCTs assessed knowledge; all demonstrated increased knowledge with PDA use (mean difference, 8.01;95%CI 4.69–11.34, p < .00001). There were many other outcomes, including behavior and acceptability, but these were too heterogenous and infrequently assessed for meaningful synthesis.
Conclusions
This review found that PDAs increase knowledge compared to standard education, though the effect size is small. PDAs are mostly considered acceptable; however, it is difficult to determine whether they improve other decision‐making components due to the limited evidence about non‐knowledge‐based outcomes.
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DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UILJ, UKNU, UL, UM, UPUK
Preemptive kidney transplantation is the preferred initial renal replacement therapy, by avoiding dialysis and reportedly maximizing patient survival. Lead time bias may account for some or all of ...the observed survival advantage, but the impact of this has not been quantified. Using the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, we included adult recipients of living donor kidney transplants during 1998‐2017. Patients were transplanted preemptively (n = 1435) or after receiving up to 6 months of dialysis (n = 712). We created a matched cohort using propensity scores, and accounted for lead time (dialysis and estimated predialysis) using left‐truncated Cox models with the primary outcome of patient survival. The median eGFR at transplantation was 6.9 mL/min per 1.73 m2 in the non‐pre‐emptive, and 9.6 mL/min per 1.73 m2 in the preemptive group. In the matched cohort (n = 1398), preemptive transplantation was not associated with a survival advantage hazard ratio (HR) for preemptive vs non‐pre‐emptive 1.12 (95% confidence interval CI 0.79‐1.61). Accounting for lead time moved the point estimates toward a survival disadvantage for preemptive transplantation (eg, HR assuming 4 mL/min per 1.73 m2/year eGFR decline, 1.21 0.85, 1.73), but in all cases the 95% CIs crossed 1. The optimal timing of preemptive living donor kidney transplantation requires further study.
This study using data from the Australia and New Zealand Dialysis and Transplant Registry, preemptive kidney transplantation finds no association with a survival advantage.
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BFBNIB, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Objectives To project the prevalence of people receiving dialysis in Australia for 2021–30 to inform service planning and health policy. Methods Estimates were based on data from 2011 to 2020 from ...the Australia & New Zealand Dialysis & Transplant (ANZDATA) Registry and the Australian Bureau of Statistics. We projected dialysis and functioning kidney transplant recipient populations for the years 2021–30. Discrete-time, non-homogenous Markov models were built on probabilities for transition between three mutually exclusive states (Dialysis, Functioning Transplant, Death), for five age groups. Two scenarios were employed – stable transplant rate vs a continued increase – to assess the impact of these scenarios on the projected prevalences. Results Models projected a 22.5–30.4% growth in the dialysis population from 14 554 in 2020 to 17 829 (‘transplant growth’) – 18 973 (‘transplant stable’) by 2030. An additional 4983–6484 kidney transplant recipients were also projected by 2030. Dialysis incidence per population increased and dialysis prevalence growth exceeded population ageing in 40–59 and 60–69 year age groups. The greatest dialysis prevalence growth was seen among those aged ≥70 years. Conclusion Modelling of the future prevalence of dialysis use highlights the increasing demand on services expected overall and especially by people aged ≥70 years. Appropriate funding and healthcare planning must meet this demand.
The inclusion of blood group– and human leukocyte antigen–compatible donor and recipient pairs (CPs) in kidney paired donation (KPD) programs is a novel strategy to increase living donor (LD) ...transplantation. Transplantation from a donor with a better Living Donor Kidney Profile Index (LKDPI) may encourage CP participation in KPD programs. We undertook parallel analyses using data from the Scientific Registry of Transplant Recipients and the Australia and New Zealand Dialysis and Transplant Registry to determine whether the LKDPI discriminates death-censored graft survival (DCGS) between LDs. Discrimination was assessed by the following: (1) the change in the Harrell C statistic with the sequential addition of variables in the LKDPI equation to reference models that included only recipient factors and (2) whether the LKDPI discriminated DCGS among pairs of prognosis-matched LD recipients. The addition of the LKDPI to reference models based on recipient variables increased the C statistic by only 0.02. Among prognosis-matched pairs, the C statistic in Cox models to determine the association of the LKDPI with DCGS was no better than chance alone (0.51 in the Scientific Registry of Transplant Recipient and 0.54 in the Australia and New Zealand Dialysis and Transplant Registry cohorts). We conclude that the LKDPI does not discriminate DCGS and should not be used to promote CP participation in KPD programs.
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BFBNIB, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Aims
Predicting progression to kidney failure for patients with chronic kidney disease is essential for patient and clinicians' management decisions, patient prognosis, and service planning. The ...Tangri et al Kidney Failure Risk Equation (KFRE) was developed to predict the outcome of kidney failure. The KFRE has not been independently validated in an Australian Cohort.
Methods
Using data linkage of the Tasmanian Chronic Kidney Disease study (CKD.TASlink) and the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA), we externally validated the KFRE. We validated the 4, 6, and 8‐variable KFRE at both 2 and 5 years. We assessed model fit (goodness of fit), discrimination (Harell's C statistic), and calibration (observed vs predicted survival).
Results
There were 18 170 in the cohort with 12 861 participants with 2 years and 8182 with 5 years outcomes. Of these 2607 people died and 285 progressed to kidney replacement therapy. The KFRE has excellent discrimination with C statistics of 0.96–0.98 at 2 years and 0.95–0.96 at 5 years. The calibration was adequate with well‐performing Brier scores (0.004–0.01 at 2 years, 0.01–0.03 at 5 years) however the calibration curves, whilst adequate, indicate that predicted outcomes are systematically worse than observed.
Conclusion
This external validation study demonstrates the KFRE performs well in an Australian population and can be used by clinicians and service planners for individualised risk prediction.
Summary at a Glance
The Kidney Failure Risk Equation (KFRE) predicts kidney failure, but has never been validated in Australia.
The KFRE score has excellent discrimination and adequate calibration. We developed an Australian recalibration factor to allow better prediction.
This study confirms that the KFRE performs well and can be used for decision‐making.
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DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UILJ, UKNU, UL, UM, UPUK
7.
The Case | A 23-year-old male with hemoptysis Irish, Georgina L.; Hesselman, Philip; Pedchenko, Vadim K. ...
Kidney international,
December 2020, 2020-12-00, 20201201, Volume:
98, Issue:
6
Journal Article
Patient and caregiver involvement can enhance the uptake and impact of research, but the involvement of patients and caregivers who are underserved and marginalized is often limited. A better ...understanding of how to make involvement in research more broadly accessible, supportive, and inclusive for patients with chronic kidney disease (CKD) and caregivers is needed. We conducted a national workshop involving patients, caregivers, clinicians, and researchers from across Australia to identify strategies to increase the diversity of patients and caregivers involved in CKD research. Six themes were identified. Building trust and a sense of safety was considered pivotal to establishing meaningful relationships to support knowledge exchange. Establishing community and connectedness was expected to generate a sense of belonging to motivate involvement. Balancing stakeholder goals, expectations, and responsibilities involved demonstrating commitment and transparency by researchers. Providing adequate resources and support included strategies to minimize the burden of involvement for patients and caregivers. Making research accessible and relatable was about nurturing patient and caregiver interest by appealing to intrinsic motivators. Adapting to patient and caregiver needs and preferences required tailoring the approach for individuals and the target community. Strategies and actions to support these themes may support more diverse and equitable involvement of patients and caregivers in research in CKD.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
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