Access to the Kidney Transplant Waiting List – a time for reflection

The limited availability of deceased donor kidneys for transplantation in Australia continues to be a matter of concern. Analysis of registry data suggests that the current renal transplant waiting list under-represents the real demand for three reasons. Firstly, a very low proportion of dialysis patients across all age groups are wait-listed for kidney transplantation; secondly, the percentage of dialysis patients listed for transplantation has fallen over time across all Australian states and territories; and thirdly, the number of patients wait-listed varies significantly across the country. We explore possible reasons for these issues and call for new eligibility criteria that are both transparent and justifiable and balance equity and utility

Access to the Kidney Transplant Waiting List – a time for reflection

postprintThe limited availability of deceased donor kidneys for transplantation in Australia continues to be a matter of concern. Analysis of registry data suggests that the current renal transplant waiting list under-represents the real demand for three reasons. Firstly, a very low proportion of dialysis patients across all age groups are wait-listed for kidney transplantation; secondly, the percentage of dialysis patients listed for transplantation has fallen over time across all Australian states and territories; and thirdly, the number of patients wait-listed varies significantly across the country. We explore possible reasons for these issues and call for new eligibility criteria that are both transparent and justifiable and balance equity and utility

Socioeconomic, Demographic and Policy Comparisons of Living and Deceased Kidney Transplantation Rates Across 53 Countries.

There are more than 1.7 million sufferers of end stage kidney disease (ESKD) worldwide and for many a donated kidney provides the only chance of regaining independence from dialysis. Unfortunately, the demand for kidneys for transplantation far exceeds the available supply. It is important, therefore, that we understand the factors that may influence kidney donation rates. While certain socio-demographic factors have been linked to kidney donation rates, few studies have examined the influence of multiple socio-demographic factors on rates of both living and deceased kidney transplantation (KT) and none have examined their comparative effect in large numbers of culturally and socio-politically diverse countries. In this study, we performed univariate and multivariate analyses of the influence of 15 socio-economic factors on both the living donor (LD) and the deceased donor (DD) kidney transplantation rates (KTR) in 54 countries. Our analyses demonstrated that factors such as UN HDI (United Nations Human Development Index), religion, education, age, healthcare expenditure, presumed consent legislation and existence of a nationally managed organ donation program were associated with higher deceased KTR. In contrast, the only factors associated with living KTR were a highly significant negative association with presumed consent and variable associations with different religions. We suggest that by identifying factors that affect kidney transplantation rates these can be used to develop programs for enhancing donor rates in individual countries where those rates are below the leading countries. Keywords Organ Donation, Kidney Transplantation; Living Donor Transplantation, Deceased Donor Kidneys, Socioeconomics; Public Policy; Demographics; Presumed Consent Lay summary Using data from 53 countries, this study shows that Human Development Index, religion, Gross Domestic Product (GDP), education, age, healthcare expenditure, presumed consent legislation and existence of a nationally managed organ donation programme were associated with higher deceased donation rates. For living transplants, a negative association was noted with presumed consent and variable associations with different religions. These factors could be targeted in countries with low donation rates

Comparative study to evaluate the effects of peritoneal and hemodialysis on peripheral nerve function

Introduction: There is no specific treatment for neuropathy in chronic kidney disease (CKD). We compared nerve function across hemodialysis (HD) and peritoneal dialysis (PD). Methods: Subjects underwent neurological assessment and neurophysiological testing using nerve excitability studies. Pre- and postdialysis studies were undertaken in HD (n = 10) and PD (n = 10) patients and were compared with stage 4 CKD patients (n = 12) and healthy controls (n = 20). Results: There were prominent differences in nerve excitability between the groups (P < 0.001). The HD group was significantly abnormal compared with all groups for excitability parameters, while the PD group demonstrated results similar to the CKD group. Pre- and postdialysis fluctuations were pronounced in the HD group, while the PD group showed less severe fluctuations. Conclusions: PD patients demonstrated greater normality of nerve excitability compared with the HD group despite similar duration of dialysis. These results suggest PD may provide greater homeostatic stability and may be neurologically beneficial. Muscle Nerve 54: 58–64, 2016

Explaining Failure Through Success: A critical analysis of reduction in road and stroke deaths as an explanation for Australia’s low deceased organ donation rates.

ABSTRACT: During the past 20 years Australian federal and state governments have funded many initiatives to bolster organ donation. Despite large investments of time, effort and money, Australia’s deceased donation rate is amongst the world’s lowest and has only slightly increased from 11.9 donors per million people (pmp) in 1990 to 13·8 donors pmp in 2010. An often-cited explanation for this situation is that Australia’s success in increasing levels of public health and safety has reduced the number of potential deceased organ donors. We refer to this as the “Failure Because of Success” hypothesis. Although commonly accepted, this hypothesis is largely untested. Analysis of health data on road trauma and stroke deaths from Australia and other OECD countries reveals that improvements in public health and safety do not provide an adequate explanation for Australia’s low organ donor rates. Keywords: Organ donation, Public safety, Brain death, Traffic fatalities, Strok

Explaining Failure Through Success: A critical analysis of reduction in road and stroke deaths as an explanation for Australia’s low deceased organ donation rates.

ABSTRACT: During the past 20 years Australian federal and state governments have funded many initiatives to bolster organ donation. Despite large investments of time, effort and money, Australia’s deceased donation rate is amongst the world’s lowest and has only slightly increased from 11.9 donors per million people (pmp) in 1990 to 13·8 donors pmp in 2010. An often-cited explanation for this situation is that Australia’s success in increasing levels of public health and safety has reduced the number of potential deceased organ donors. We refer to this as the “Failure Because of Success” hypothesis. Although commonly accepted, this hypothesis is largely untested. Analysis of health data on road trauma and stroke deaths from Australia and other OECD countries reveals that improvements in public health and safety do not provide an adequate explanation for Australia’s low organ donor rates. Keywords: Organ donation, Public safety, Brain death, Traffic fatalities, Strok

Potassium control in chronic kidney disease: implications for neuromuscular function

In Australia, approximately 1.7 million adults have evidence of chronic kidney disease (CKD). This complex disease can result in a multitude of complications, including hyperkalaemia, which is common and well recognised. The advent of new therapeutics aimed at lowering serum potassium has raised the possibility of optimising potassium control to enable greater use of renin–angiotensin–aldosterone system inhibitors in the management of CKD. Recent studies suggest that hyperkalaemia also has implications for peripheral neuropathy in CKD, a complication that substantially contributes to patient morbidity. This review examines evidence of the relationship between potassium and peripheral neuropathy, with a discussion of clinical implications. We searched PubMed for original and review articles using pre-specified key words, clinical guidelines and population data. The major findings were that contemporary CKD cohorts demonstrate a high prevalence of peripheral neuropathy, even in stage 3–4 CKD, including those without diabetes. The severity of the problem has been emphasised by an ominous rise in foot complications and amputation rates in dialysis patients, highlighting the need for increased awareness of the condition in earlier stages of CKD and targeted treatment strategies. It is likely that the pathophysiology of peripheral neuropathy in CKD is multifaceted, with potential influences from potassium, vascular abnormalities, diabetes, inflammation and unknown middle molecules. Despite these complexities, the relationship between potassium and nerve function in dialysis has been well established, and recent research in stage 3–4 CKD suggests that assertive potassium control may improve neuromuscular outcomes in CKD. These small studies should be confirmed in large, multicentre settings

An International Comparison of the Effect of Policy Shifts to Organ Donation Following Cardiocirculatory Death (DCD) on Donation Rates After Brain Death (DBD) and Transplantation Rates

During the past decade an increasing number of countries have adopted policies that emphasize donation after cardiocirculatory death (DCD) in an attempt to address the widening gap between the demand for transplantable organs and the availability of organs from donation after brain death (DBD) donors. In order to examine how these policy shifts have affected overall deceased organ donor (DD) and DBD rates, we analyzed deceased donation rates from 82 countries from 2000–2010. On average, overall DD, DBD and DCD rates have increased over time, with the proportion of DCD increasing 0.3% per year (p = 0.01). Countries with higher DCD rates have, on average, lower DBD rates. For every one-per million population (pmp) increase in the DCD rate, the average DBD rate decreased by 1.02 pmp (95% CI: 0.73, 1.32; p<0.0001). We also found that the number of organs transplanted per donor was significantly lower in DCD when compared to DBD donors with 1.51 less transplants per DCD compared to DBD (95% CI: 1.23, 1.79; p<0.001). Whilst the results do not infer a causal relationship between increased DCD and decreased DBD rates, the significant correlation between higher DCD and lower DBD rates coupled with the reduced number of organs transplanted per DCD donor suggests that a national policy focus on DCD may lead to an overall reduction in the number of transplants performed