reducing barriers to living donor kidney transplantation ... · cumulative bpar probability history...
TRANSCRIPT
Reducingbarrierstolivingdonorkidneytransplanta5oninOntario–adap5ngtheExploreTransplantEduca5onProgram
IstvanMucsiUniversityHealthNetwork,Toronto,Ontario,
Canada
Email:[email protected]
2016-06-17 RenalTransplantSymposium2016
Disclosure
• TheExploreTransplantOntarioadaptaDonprojectreceivedunrestrictededucaDonalsupportfromAstellasPharmaCanada
2016-06-17 RenalTransplantSymposium2016
• Whykidneytransplant;whylivingdonorkidneytransplant–DOWEHAVEAPROBLEM??
• PotenDallymodifiablebarrierstoKTandLDKT– Psychosocialbarriers– Ethnoculturalbarriers
• HelpingpaDentsconsidertransplant–educa5on–ExploreTransplant
• AdapDngExploreTransplant–ExploreTransplantOntario
2016-06-17 RenalTransplantSymposium2016
CST Consensus Guidelines on Kidney Transplant, CMAJ 2005
CMAJ•November8,2005•173(10)|
2016-06-17 RenalTransplantSymposium2016
hQp://ichoosekidney.emory.edu/
(TransplantaDon2016;100:630–639)
2016-06-17 RenalTransplantSymposium2016
hQp://ichoosekidney.emory.edu/
(TransplantaDon2016;100:630–639)
2016-06-17 RenalTransplantSymposium2016
ProjectedlifeexpectancyaTerESRDonsetbyrecipientageandtreatmentmodality.
Schold J D , and Meier-Kriesche H CJASN 2006;1:532-538
2016-06-17 RenalTransplantSymposium2016
AmericanJournalofTransplanta5on2008;8:58–68
2016-06-17 RenalTransplantSymposium2016
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
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
0
100
200
300
400
500
600
700
800
900
2016-06-17 RenalTransplantSymposium2016
2016-06-17 RenalTransplantSymposium2016
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.
2016-06-17 RenalTransplantSymposium2016
Lancet2015;385:2003–13
2016-06-17 RenalTransplantSymposium2016
AmericanJournalofTransplanta5on2014;14:1562–1572
AmericanJournalofTransplanta5on2014;14:1562–1572
2016-06-17 RenalTransplantSymposium2016
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;
• Recurrentproblemswithnon-adherencetodialysis,drugseekingbehavior,useofrecr.drugs,narcoDcanalgesics
• Non-adherencetoHD,no-showforseveralappointments
• 35yo,AfricanCanadianmale• ESKDduetoGN• OnPDx3yrs,recentlyswitchedtoHD• NomajorcomorbidiDes• Liveswithcommonlawpartner,stablerelaDonship
• Pt.wasdeclinedtobewaitlisted–heaccepted
MsC–15oct
• 61yoF• ESKD,typ1DM• PDsince2009• T1DM,HTN,DLP• ReDnopathy,neuropathy,
gastroparesis• CAD,AMI2002• AMI2010,PCI• CABG2012
• ECD15oct• IGF• NSTEMIpostop• D/CwithcreatN
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
2016-06-17 RenalTransplantSymposium2016
OnewordofcauDon:increasingkidneytransplantaDonandlivingdonorkidneytransplantaDon
Increasingtherecipientanddonorpool
Thiscannotbesuccessfulwithoutrethinkingandimprovingpost-transplantandpost-dona5oncare
SAFELY
SAFELY
Psychosocialbarriers
• MentalHealthissuesarefrequentinpaDentswithEndStageRenalDisease– ~40%ofpaDentsondialysisexperiencedepression(Szeifert2011,
Cukor2007)• Associatedwithmortalityandpoorqualityoflife(KimmelPL2000,LopesAA2002)
– RelaDvelyneglected– MaybeapotenDalbarriertotransplantaDon
2016-06-17 RenalTransplantSymposium2016
CourtesyofG.Rodin
2016-06-17 RenalTransplantSymposium2016
NephrolDialTransplant(2012)27:2107–2113
35-45%ofWLpaDentshadhighriskofdepression
2016-06-17 RenalTransplantSymposium2016
!
Univariablehazardra5o(95%CI):0.81(0.70,0.93)
2016-06-17 RenalTransplantSymposium2016
ReferraltotransplantWUcomple5on,byhistoryofpsychiatricdisorders
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
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
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
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
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
Ethnoculturalbarriers
2016-06-17 RenalTransplantSymposium2016
AmericanJournalofTransplanta5on2013;13:1557–1565
2016-06-17 RenalTransplantSymposium2016
KidneyInternaDonal(2007)72,499–504;
2016-06-17 RenalTransplantSymposium2016
PLOSONE|DOI:10.1371/journal.pone.0124321July31,2015
2016-06-17 RenalTransplantSymposium2016
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
2016-06-17 RenalTransplantSymposium2016
2016-06-17 RenalTransplantSymposium2016
LDtransplantversushavingapoten5alLDatreferral
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
ASSESSINGPATIENTREPORTEDMEASURES
CAPTURINGTHEPATIENTPERSPECTIVE
Study Questionnaires • TRANSPLANTDECISIONMAKINGSURVEY• ILLNESSINTRUSIVESNESSRATINGSCALE• EXPERIENCEOFCLOSERELATIONSHIPSCALE• KIDNEYDISEASEQUALITYOFLIFE• FATIGUESEVERITYSCALE(FSS)• MOSSOCIALSUPPORT• SHORTLITERACYSURVEY• SOCIO-DEMOGRAPHIC&CULTURALQUESTIONNAIRE• PATIENTRESPONSEQUESTIONNAIRE• DART(PHQ-9,GAD,ESAS,SDI)
Didyoufindthetaskofcomple5ngtheques5onnairesONTHETABLETCOMPUTERtoodifficultor5ring?
0
20
40
60
80
100
No Yes
%
0
20
40
60
80
100
Notatall Veryliile Somewhat Agreatextent
Someonecompletedit
forme
%
Didyouneedsomeone’shelptocompletetheques5onnaire?
Sample Question from DART (PHQ-9,GAD,ESAS,SDI)
Propor5onofpa5entswithdistress(n=64)
0102030405060708090
100
Depression Anxiety SocialdifficulDes Anydistress
%
Factorsassociatedwithdistress(any)
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
TxknowledgevsLDdonoriden5fied
Reducingbarrierstolivingdonorkidneytransplanta5oninOntario–adap5ngtheExploreTransplantEduca5onProgram
RoadtoTransplantRequires:
• LearnabouttransplantasanopDon
• BeginevaluaDon– (beidenDfiedandaccept)
• Aiendtransplantappointments
• Getlistedfortransplant• Completeyearlyre-evaluaDon• Findamatchingkidney• Receiveadeceasedorlivingdonortransplant
2016-06-17 RenalTransplantSymposium2016
JAmSocNephrol25:ccc–ccc,2014.doi:10.1681/ASN.2013121298
2016-06-17 RenalTransplantSymposium2016
ClinJAmSocNephrol▪:ccc–ccc,2015.doi:10.2215/CJN.00950115
2016-06-17 RenalTransplantSymposium2016
TransplantaDon2014;00:00Y00
2016-06-17 RenalTransplantSymposium2016
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%
2016-06-17 RenalTransplantSymposium2016
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
2016-06-17 RenalTransplantSymposium2016
• Review,updateandadaptExploreTransplantcontenttoCanadianhealthcaresystem
• IncludeOntariophysicians,paDentsandlivingdonorsinvideos
ExploreTransplant–
OntarioAdapta5on
2016-06-17 RenalTransplantSymposium2016
Engagementfromall6Ontariotransplantprograms
2016-06-17 RenalTransplantSymposium2016
2016-06-17 RenalTransplantSymposium2016
2016-06-17 RenalTransplantSymposium2016
2016-06-17 RenalTransplantSymposium2016
2016-06-17 RenalTransplantSymposium2016
2016-06-17 RenalTransplantSymposium2016
2016-06-17 RenalTransplantSymposium2016
2016-06-17 RenalTransplantSymposium2016
Nextsteps
• Pilottraining–MAY10,UHN
• PilotstudyofETO–MSH-UHNAMOInnova5onfund
• ProvincialimplementaDonstudy(Dr.A.Garg)ofamulDfacetedintervenDontoincreaselivingdonorkidneytransplant–SPOR-CAN-SOLVED-CKD
2016-06-17 RenalTransplantSymposium2016
2016-06-17 RenalTransplantSymposium2016
Alsospecialthankstothedialysisandtransplantprofessionalsfortheircontribu5onfrom:
• KidneyFoundaDonofCanada
• KingstonGeneralHospital,Kingston,Ontario
• LondonHealthSciencesCentre,London,Ontario
• St.Joseph`sHealthcare,Hamilton,Ontario
• St.Michael`sHospital,Toronto,Ontario
• TheOiawaHospital,Oiawa,Ontario
• UniversityHealthNetwork,Toronto,Ontario
2016-06-17 RenalTransplantSymposium2016
2016-06-17 RenalTransplantSymposium2016
Specialthanksfortheirhelpwiththemanagementoftheproject:
• Ms.DorothyWong• Ms.HeatherFord• Ms.RitaKruger• Ms.WilmaAranha• Mr.BasdeBeer• Mr.AlexanderGluhushkinandMr.AnthonyOlsen• Studentsofmyresearchteam
2016-06-17 RenalTransplantSymposium2016
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:
2016-06-17 RenalTransplantSymposium2016