reducing barriers to living donor kidney transplantation ... · cumulative bpar probability history...
TRANSCRIPT
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Reducingbarrierstolivingdonorkidneytransplanta5oninOntario–adap5ngtheExploreTransplantEduca5onProgram
IstvanMucsiUniversityHealthNetwork,Toronto,Ontario,
Canada
Email:[email protected]
2016-06-17 RenalTransplantSymposium2016
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Disclosure
• TheExploreTransplantOntarioadaptaDonprojectreceivedunrestrictededucaDonalsupportfromAstellasPharmaCanada
2016-06-17 RenalTransplantSymposium2016
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• Whykidneytransplant;whylivingdonorkidneytransplant–DOWEHAVEAPROBLEM??
• PotenDallymodifiablebarrierstoKTandLDKT– Psychosocialbarriers– Ethnoculturalbarriers
• HelpingpaDentsconsidertransplant–educa5on–ExploreTransplant
• AdapDngExploreTransplant–ExploreTransplantOntario
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CST Consensus Guidelines on Kidney Transplant, CMAJ 2005
CMAJ•November8,2005•173(10)|
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hQp://ichoosekidney.emory.edu/
(TransplantaDon2016;100:630–639)
2016-06-17 RenalTransplantSymposium2016
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hQp://ichoosekidney.emory.edu/
(TransplantaDon2016;100:630–639)
2016-06-17 RenalTransplantSymposium2016
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ProjectedlifeexpectancyaTerESRDonsetbyrecipientageandtreatmentmodality.
Schold J D , and Meier-Kriesche H CJASN 2006;1:532-538
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AmericanJournalofTransplanta5on2008;8:58–68
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2016-06-17 RenalTransplantSymposium2016
Ø Accordingtothelatestavailabledata,90.8%and81.4%ofkidneystransplantedintoadultsfromlivinganddeceaseddonors,respecDvely,weres5llfunc5oningatleast5yearsaTertransplant.
Ø Accordingtothelatestavailabledata,43.2%ofpa5entsondialysistreatmentssurvivedatleast5years(8398pa5ents).
Ø WL=3,377pa5ents
Ø Ofthe20,690paDentsondialysis,morethanthree-quarterswerereceivinginsDtuDonalhemodialysis,themostexpensivetreatmentopDon
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NumberofKidneyTransplantsbyDonorType,Adult(18+),2005to2014
Source: Canadian Organ Replacement Register, 2015, CIHI
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Deceased 572 689 727 713 731 725 758 809 807 806 Living 411 461 458 453 441 466 438 435 484 434
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Adult(18+)LivingDonorKidneyTransplantsbyYearandProvince,2005to2014
Source: Canadian Organ Replacement Register, 2015, CIHI
0
50
100
150
200
250
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Ont.
B.C.
Alta.
Que.
N.S.
Man.
Sask.
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Lancet2015;385:2003–13
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AmericanJournalofTransplanta5on2014;14:1562–1572
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AmericanJournalofTransplanta5on2014;14:1562–1572
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Cases
• 68yoinuitmale,livinginMox18mosonHD–potenDallivedonor;T2DM,PVD,CAD
• 65yomale,onHD;t2dm,HCV–failedIFN;
• 35yocreefemale;onHDx1yr;T2DM,BMI38
• 68yomaleonHDx2yrs;T2DM,CAD,BMI41;AC145cm;
• 38yoAAfemaleonHDx18mos;SSD;stroke4mosago;OFO
• 40yoAAfemale,onHDx3yrs;HIV+;previousinfs;
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• Recurrentproblemswithnon-adherencetodialysis,drugseekingbehavior,useofrecr.drugs,narcoDcanalgesics
• Non-adherencetoHD,no-showforseveralappointments
• 35yo,AfricanCanadianmale• ESKDduetoGN• OnPDx3yrs,recentlyswitchedtoHD• NomajorcomorbidiDes• Liveswithcommonlawpartner,stablerelaDonship
• Pt.wasdeclinedtobewaitlisted–heaccepted
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MsC–15oct
• 61yoF• ESKD,typ1DM• PDsince2009• T1DM,HTN,DLP• ReDnopathy,neuropathy,
gastroparesis• CAD,AMI2002• AMI2010,PCI• CABG2012
• ECD15oct• IGF• NSTEMIpostop• D/CwithcreatN
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MrT–15oct• 77yoAAM• ESKDsince2011• T2DM,HTN• CAD–noMI• ReDnopathy–legallyblind• GERD• ProstateCA–
prostatectomyin2006• Liveswithyoungerwife• Goodsupport• Wantstobefreefrom
dialysis,wantstotravel
• ECD/DCD15oct• DGF• d/cwithcreat200,
declining
Someongoingissues,creatcca160,saysitisbeiernowthanbefore;madehisfirsttriptovisiDngfamilyinFloridainApril
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OnewordofcauDon:increasingkidneytransplantaDonandlivingdonorkidneytransplantaDon
Increasingtherecipientanddonorpool
Thiscannotbesuccessfulwithoutrethinkingandimprovingpost-transplantandpost-dona5oncare
SAFELY
SAFELY
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Psychosocialbarriers
• MentalHealthissuesarefrequentinpaDentswithEndStageRenalDisease– ~40%ofpaDentsondialysisexperiencedepression(Szeifert2011,
Cukor2007)• Associatedwithmortalityandpoorqualityoflife(KimmelPL2000,LopesAA2002)
– RelaDvelyneglected– MaybeapotenDalbarriertotransplantaDon
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CourtesyofG.Rodin
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NephrolDialTransplant(2012)27:2107–2113
35-45%ofWLpaDentshadhighriskofdepression
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!
Univariablehazardra5o(95%CI):0.81(0.70,0.93)
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ReferraltotransplantWUcomple5on,byhistoryofpsychiatricdisorders
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Mul5variableadjustedlikelihoodofcomple5ngthetransplantWUwithintwoyearsaTerreferralforpa5entswiththe
historyofpsychiatricdisordersornon-adherence
MentalHealth HazardRa5o(95%C.I.)HistoryofPsychiatricdisorder(Yesvs.No) 0.81(0.70,0.95)
Adjustedfor:age,sex,maritalstatus,EnglishcommunicaDon,race,OntarioMarginalizaDonIndexandthehistoryof:historyofdiabetes,coronaryarterydisease/myocardialinfarcDon,heartfailure,strokeandperipheralvasculardisease,chroniclungdisease,ornon-skincancer2016-06-17 RenalTransplantSymposium2016
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Log Rank P = 0.15
0.00
0.10
0.20
Cum
ulativ
e BP
AR p
roba
bility
207 183 175 169 160 150 139History of MH disorders748 676 656 642 601 556 512No history of MH disorders
Number at risk
0 4 8 12 16 20 24
Months post-transplant
History of MH disordersNo history of MH disorders
Biopsy-provenacuterejec5onbyhistoryofMH
Log Rank P = 0.04
0.00
0.10
0.20
Cumu
lative
BPA
R pr
obab
ility
108 97 92 90 78 72 63History of non-adherence847 762 739 721 683 634 588No history of non-adherence
Number at risk
0 4 8 12 16 20 24
Months post-transplant
History of non-adherenceNo history of non-adherence
Biopsy-provenacuterejec5onbyhistoryofNA
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Mul5variableadjustedlikelihoodofBPARforpa5entswithahistoryofMHorNAVariables HazardRa5o
(95%C.I.)Historyofmentalhealthdisorder(YesversusNo) 1.31(0.87,1.99)
Historyofnon-adherence(YesversusNo) 1.26(0.76,2.09)
Adjustedfor:age,sex,race,donortype,ECD,DGF,HLAmismatchandhistoryofdiabetes
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Log Rank P = 0.72
0.00
0.20
0.40
0.60
0.80
1.00
Cum
ulativ
e to
tal g
raft
failu
re
207 196 162 124 92 66 40 24 11History of MH disorders748 708 573 469 367 267 195 131 78No history of MH disorders
Number at risk
0 12 24 36 48 60 72 84 96
Months post-transplant
History of MH disordersNo history of MH disorders
TotalgraTfailurebyhistoryofMH
Log Rank P = 0.24
0.00
0.20
0.40
0.60
0.80
1.00
Cum
ulativ
e to
tal g
raft
failu
re
108 102 76 55 38 18 8 5 2History of non-adherence847 802 659 538 421 315 227 150 87No history of non-adherence
Number at risk
0 12 24 36 48 60 72 84 96
Months post-transplant
History of non-adherenceNo history of non-adherence
TotalgraTfailurebyhistoryofNA
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Mul5variableadjustedlikelihoodofTGFforpa5entswithahistoryofMHorNA
Variables HazardRa5o(95%C.I.)
Historyofmentalhealthdisorder(YesversusNo) 0.96(0.56,1.64)
Historyofnon-adherence(YesversusNo) 1.65(0.89,3.08)
Adjustedfor:age,sex,race,donortype,ECD,DGF,HLAmismatchandhistoryofdiabetes
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Ethnoculturalbarriers
2016-06-17 RenalTransplantSymposium2016
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AmericanJournalofTransplanta5on2013;13:1557–1565
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KidneyInternaDonal(2007)72,499–504;
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PLOSONE|DOI:10.1371/journal.pone.0124321July31,2015
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Race/ethnicity–accesstotransplant,LDKT
Log Rank P < 0.001
0.00
0.25
0.50
0.75
1.00
Cum
ulat
ive tr
ansp
lant
atio
n pr
obab
ility
524 406 237 106 38Other/unknown143 82 45 29 9Indo Asian164 116 53 25 6East Asian182 119 68 36 18Black756 395 201 100 42White
Number at risk
0 2 4 6 8Years from referral date
WhiteBlackEast AsianIndo AsianOther/unknown
Transplant LDKT
Log Rank P < 0.001
0.00
0.25
0.50
0.75
1.00
Cum
ulat
ive tr
ansp
lant
atio
n pr
obab
ility
524 406 237 106 38Other/unknown143 82 45 29 9Indo Asian164 116 53 25 6East Asian182 119 68 36 18Black756 395 201 100 42White
Number at risk
0 2 4 6 8Years from referral date
White BlackEast Asian Indo AsianOther/unknown
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LDtransplantversushavingapoten5alLDatreferral
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Psychosocialandethno-culturalbarrierstolivingdonorkidneytransplanta5on
I.Mucsi,A.D.Waterman,S.J.Kim,J.S.Zaltzman,K.P.Fung,D.Buchman,R.NissimandM.
Novak
ThisstudywillinvesDgatereadinesstoacceptlivingdonorkidneytransplant(LDKT)andalsopsychosocialandethno-culturalbarrierstoaccepDngLDKTamongpaDentswithchronickidneydisease(CKD)–referredforpre-transplantassessment
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ASSESSINGPATIENTREPORTEDMEASURES
CAPTURINGTHEPATIENTPERSPECTIVE
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Study Questionnaires • TRANSPLANTDECISIONMAKINGSURVEY• ILLNESSINTRUSIVESNESSRATINGSCALE• EXPERIENCEOFCLOSERELATIONSHIPSCALE• KIDNEYDISEASEQUALITYOFLIFE• FATIGUESEVERITYSCALE(FSS)• MOSSOCIALSUPPORT• SHORTLITERACYSURVEY• SOCIO-DEMOGRAPHIC&CULTURALQUESTIONNAIRE• PATIENTRESPONSEQUESTIONNAIRE• DART(PHQ-9,GAD,ESAS,SDI)
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Didyoufindthetaskofcomple5ngtheques5onnairesONTHETABLETCOMPUTERtoodifficultor5ring?
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No Yes
%
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Notatall Veryliile Somewhat Agreatextent
Someonecompletedit
forme
%
Didyouneedsomeone’shelptocompletetheques5onnaire?
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Sample Question from DART (PHQ-9,GAD,ESAS,SDI)
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Propor5onofpa5entswithdistress(n=64)
0102030405060708090
100
Depression Anxiety SocialdifficulDes Anydistress
%
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Factorsassociatedwithdistress(any)
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Txknowledgevshavingalivingdonoriden5fied
0%
20%
40%
60%
80%
100%
Txknowledge
low
Txknowledge
high
LDyes
LDno
0%
20%
40%
60%
80%
100%
Txknowledge
low
Txknowledge
high
LDlate
LDearly
% %
TxknowledgevsLDreadiness
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TxknowledgevsLDdonoriden5fied
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Reducingbarrierstolivingdonorkidneytransplanta5oninOntario–adap5ngtheExploreTransplantEduca5onProgram
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RoadtoTransplantRequires:
• LearnabouttransplantasanopDon
• BeginevaluaDon– (beidenDfiedandaccept)
• Aiendtransplantappointments
• Getlistedfortransplant• Completeyearlyre-evaluaDon• Findamatchingkidney• Receiveadeceasedorlivingdonortransplant
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JAmSocNephrol25:ccc–ccc,2014.doi:10.1681/ASN.2013121298
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ClinJAmSocNephrol▪:ccc–ccc,2015.doi:10.2215/CJN.00950115
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TransplantaDon2014;00:00Y00
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Transplant Education Practices in Dialysis Centers
Providers engaging in this practice:
(N=1544)
Orally recommend patients learn more about transplant themselves 72%
Orally recommend being evaluated for transplant 69%
Refer patients to an external transplant educational program 44%
Distribute transplant center phone numbers 37% Detailed discussion about advantages/risks of DDKT 21% Detailed discussion about advantages/risks of LDKT 21%
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WhatisExploreTransplant?
§ Comprehensive education program that helps kidney patients make informed transplant decisions § Video, print resources with patient and
donor stories § Discussion of risks/benefits of transplant
and living donation § Individually-tailored conversations
based on what is important to patient § Educational materials for dialysis patients,
family members & living donors
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• Review,updateandadaptExploreTransplantcontenttoCanadianhealthcaresystem
• IncludeOntariophysicians,paDentsandlivingdonorsinvideos
ExploreTransplant–
OntarioAdapta5on
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Engagementfromall6Ontariotransplantprograms
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Nextsteps
• Pilottraining–MAY10,UHN
• PilotstudyofETO–MSH-UHNAMOInnova5onfund
• ProvincialimplementaDonstudy(Dr.A.Garg)ofamulDfacetedintervenDontoincreaselivingdonorkidneytransplant–SPOR-CAN-SOLVED-CKD
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Alsospecialthankstothedialysisandtransplantprofessionalsfortheircontribu5onfrom:
• KidneyFoundaDonofCanada
• KingstonGeneralHospital,Kingston,Ontario
• LondonHealthSciencesCentre,London,Ontario
• St.Joseph`sHealthcare,Hamilton,Ontario
• St.Michael`sHospital,Toronto,Ontario
• TheOiawaHospital,Oiawa,Ontario
• UniversityHealthNetwork,Toronto,Ontario
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Specialthanksfortheirhelpwiththemanagementoftheproject:
• Ms.DorothyWong• Ms.HeatherFord• Ms.RitaKruger• Ms.WilmaAranha• Mr.BasdeBeer• Mr.AlexanderGluhushkinandMr.AnthonyOlsen• Studentsofmyresearchteam
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Specialthanksto:
• Aarushi Bansal• Amanda Sissons• Candice Richardson• Dmitri Belenko• Eleanor Warsmann • Evan Tang• Eszter Mucsi• FranzMarie Gumabay• Kefan Bei• Luca UgenD• Luke Dingwell• Michael Jeanneie• Nathaniel Edwards• Priscilla Yung• Sarah Cao• Yalinie Kulandaivelu
Dr.S.J.Kim,Ms.YanhongLi,Mr.OlusegunFamureMs.DorothyWong Ms.HeatherFordCurrentandpaststudentsinmygroup:
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