Living donation is associated with an increased incidence of the following. A. Hypertension B. Proteinuria C. CKD D. DM E. Preeclampsia
Please justify your answer by giving the incidence of the event if it is a real risk. THERE IS NO ANNOUNCEMENT FOR THIS CHALLENGE. The reward will be restricted to the successful contributors ONLY.
A. This may be true in high risk indiviuals e.g. African American, Hispanic, high BMI and older donor= 50% increased relative risk (Lentin KL et.al. & Muller TF et al. 2012)
B. This is true as well but the amount of proteinuria is usually small. In meta-analysis,the donrs had protein excretion of 83 mg/ day versus 147 mg/day in the contol group, 95% CI 24-108
C. This true in one study, the hazards ratio for ESRD was 11.38. In another study it was
31/1000
D. Correct, donating to family member with type1 DM increase the risk , HR is 2.97 (Ibrahim et al.), BMI > 30 HR 2.97, AGE > 45 HR 1.46
E. Correct statment, preeclampsia was in 11% of donors compared to the non-donors control 5% ( Amit X, Garg et.al)
The risk of hypertension was found to be higher in donors compared to non donors, one study found that hypertension occur in 4, 10, and 51 % at 5, 10, and 40 years, respectively (1). Another study reported 6 mmHg increase in the SBP and 4 mm Hg increase in the DBP in donor compared to non-donors after at least 5 years (2), further study found increase in the incidence of HTN in donors when compared to non-donors (16.3 % versus 11.9 %, respectively) after a mean of 6 years [3].
On the other hand, a prospective study evaluating 182 donors found that there is no significant difference in ABPM between donors and matched control (4)
All the previous studies were composed mainly of white donors and controls, 103 African-American donors were evaluated regarding the incidence of HTN and compared to matched African-American controls and they found a significant increase in the incidence of hypertension in donors compared to non-donors (40.8 versus 17.9 percent, respectively) [5].
Lastly a study composed of the 2 races reported 19% increase in the risk of hypertension in donors compared to matched non donors and this was not affected by race [6].
The risk factors for the development of HTN after kidney donation includes, higher BP before donation, African American and Hispanic ethnity, obesity and elderly, these patients should be educated about the risk of developing hypertension after donation
B- Proteinuria : Correct
Albuminuria occur more commonly after donation when compared to healthy non donors, A systematic review and meta-analysis evaluating 5048 kidney donors assessed proteinuria after 1-25 years (average 7 years) and found that average 24 h urine protein was slightly higher than control
C- CKD : Correct
After donation it was found that there is an initial decrease in GFR followed by increase to the normal age anticipated GFR, after 10 years of donation and the GFR was 10 ml/min lower than controls (7)
A slight increase in the risk of ESRD observed in donors (8, 9), one study found that ESRD occur in 300 per million donors and 100 per million healthy non donors, and the median time to ESRD in donors was 18.7 years (4), another study found that ESRD occur after 15 years in 30.8 per 10,000 donors compared to 3.9 per 10,000 healthy non donors, on the other hand some studies fail to find an increase in risk of ESRD in donors over nearly 10 years (10)
The risk of ESRD increase in current or former smoker, obese, diabetic, African- American and patients with albuminuria or renal impairment (11), for example it was found that the risk of ESRD increase by 7% for each unit increase in BMI
The cause of ESRD among donors were found to be mainly due to an immunological cause (SLE, ANCA vasculitis, SLE, glomerulonephritis) which may be explained by biological relation between donor and recipients so the donor may be at risk, so whether donation have a rule or not for this increase in the risk of ESRD is uncertain (12)
D. DM : False
It was found that around 5% develop DM2 after 17.7 ± 9.0 years after donation, this percent is similar to the incidence of DM2 in general population. Moreover, the risk factors for development of DM2 were not different from general population including obesity (BMI>30 kg/m2), male sex and smoking
So … kidney donation is not associated with any added risk regarding development and complication of DM2
E. Preeclampsia : Correct
GH and preeclampsia was found to be 2 folds higher in female kidney donors when compared to non-donors (5.7 versus 2.6 %), thus some recommend completing childbearing before donation (13) or at least informing the donor with the risk of preeclampsia when getting pregnancy with a single kidney (13)
Nevertheless, donation is associated with good fetal and maternal outcomes
REFERANCES
1- Sanchez OA, Ferrara LK, Rein S, et al. Hypertension after kidney donation: Incidence, predictors, and correlates. Am J Transplant 2018; 18:2534.
2- Boudville N, Prasad GV, Knoll G, et al. Meta-analysis: risk for hypertension in living kidney donors. Ann Intern Med 2006; 145:185.
3- Garg AX, Prasad GV, Thiessen-Philbrook HR, et al. Cardiovascular disease and
hypertension risk in living kidney donors: an analysis of health administrative data in Ontario, Canada. Transplantation 2008; 86:399.
4- Kasiske BL, Anderson-Haag T, Israni AK, et al. A prospective controlled study of living kidney donors: three-year follow-up. Am J Kidney Dis 2015; 66:114.
5- Doshi MD, Goggins MO, Li L, Garg AX. Medical outcomes in African American live kidney donors: a matched cohort study. Am J Transplant 2013; 13:111.
6- Holscher CM, Haugen CE, Jackson KR, et al. Self-Reported Incident Hypertension and Long-Term Kidney Function in Living Kidney Donors Compared with Healthy Nondonors. Clin J Am Soc Nephrol 2019; 14:1493.
7- Moody WE, Ferro CJ, Edwards NC, et al. Cardiovascular Effects of Unilateral Nephrectomy in Living Kidney Donors. Hypertension 2016; 67:368.
9- Muzaale AD, Massie AB, Wang MC, et al. Risk of end-stage renal disease following live kidney donation. JAMA 2014; 311:579.
10- Cherikh WS, Young CJ, Kramer BF, et al. Ethnic and gender related differences in the risk of end-stage renal disease after living kidney donation. Am J Transplant 2011;
11:1650.
11- Grams ME, Sang Y, Levey AS, et al. Kidney-Failure Risk Projection for the Living Kidney-Donor Candidate. N Engl J Med 2016; 374:411.
12- Lam NN, Lentine KL, Garg AX. End-stage renal disease risk in live kidney donors: what have we learned from two recent studies? Curr Opin Nephrol Hypertens 2014; 23:592.
13- LaPointe Rudow D, Hays R, Baliga P, et al. Consensus conference on best practices in live kidney donation: recommendations to optimize education, access, and care. Am J Transplant 2015; 15:914.
Answer: A, B C and E A is true: 1. In the national study by NIH-USA, new-onset diabetes was rare, but approximately 3% of donors developed new-onset hypertension within 2 years of donor nephrectomy(1). 2. Kidney donation was independently associated with a 19% higher risk for hypertension, regardless of race (although baseline hypertension risk was 27% higher for blacks generally)(2).
B is true: Most reported data suggest that proteinuria increased in the living kidney donor population, and the prevalence of microalbuminuria in living donors varied from 11.5% to 34% in different studies(3). C is true: Recent data support that living donors may experience a small increased risk of severe CKD and ESKD compared with healthy nondonors. For most donors, the 15-year risk of kidney failure is <1%, but for certain populations, such as young, black men, this risk may be higher.(4)
D is false: Diabetes is rare in living kidney donor as per NIH-USA(1).
E is true: Gestational hypertension or preeclampsia was more likely to be diagnosed in kidney donors than in matched nondonors with similar indicators of baseline health (11% in donors s v 5% in non-donors) (5).
Reference 1. Holscher CM, Bae S, Thomas AG, Henderson ML, Haugen CE, DiBrito SR, Muzaale AD, Garonzik Wang JM, Massie AB, Lentine KL, Segev DL. Early Hypertension and Diabetes After Living Kidney Donation: A National Cohort Study. Transplantation. 2019 Jun;103(6):1216-1223. doi: 10.1097/TP.0000000000002411. PMID: 30247449; PMCID: PMC6428622. 2. 9. Ibrahim HN, Foley R, Tan L et al. Long-term consequences of kidney donation. N Engl J Med 2009; 360: 459–469 [PMC free article][PubMed] [Google Scholar] [Ref list] 3. Fehrman-Ekholm I, Elinder CG, Stenbeck M et al. Kidney donors live longer. Transplantation 1997; 64: 976–978 4. Reese PP, Boudville N, Garg AX. Living kidney donation: outcomes, ethics, and uncertainty. Lancet. 2015 May 16;385(9981):2003-13. doi: 10.1016/S0140-6736(14)62484-3. PMID: 26090646. 5. Ibrahim HN, Foley R, Tan L et al. Long-term consequences of kidney donation. N Engl J Med 2009; 360: 459–469 [PMC free article][PubMed] [Google Scholar] [Ref list]
The answer is E Donor nephrectomy does not appear to increase long-term mortality compared with controls, nor to increase ESRD risk among white donors. Within the donor population, the likelihood of post-donation chronic kidney disease, ESRD, and medical comborbidities such as hypertension and diabetes are relatively higher among some donor sub-groups, such as African Americans and obese donors, but the impact of uni-nephrectomy on the lifetime risks of adverse events expected without nephrectomy in these sub-groups is not yet defined. 5.5%associted risk of preclmpsis in some ofstudies References1. Terasaki PI, Cecka JM, Gjertson DW, Takemoto S. High survival rates of kidney transplants from spousal and living unrelated donors. The New England journal of medicine. 1995 Aug 10;333(6):333–336. [PubMed] [Google Scholar]
2. Klein AS, Messersmith EE, Ratner LE, Kochik R, Baliga PK, Ojo AO. Organ donation and utilization in the United States, 1999–2008. Am J Transplant. 2010 Apr;10(4 Pt 2):973–986. [PubMed] [Google Scholar]
3. OTPN/HRSA. [Access Date June 1, 2011];National Data, Transplants by Donor Type.
Living donation is associated with an increased incidence of the following.
A. Hypertension- true the incidence is 10-20% post donation[1].
B. Proteinuria- True the incidence is 11,5-34% post kidney donation[2].
C. CKD- True the incidence is 10% at 44 years post donation, half of them occures after age of 64 years[3].
D. DM- False there is no increase occurrence of DM among kidney donors in comparison of general population[4].
E. Preeclampsia- True the incidence was 11% vs 5% in non donors[5]
References: [1] Abdellaoui I, Sahtout W, Awatef A, Zallama D, Achour A. Prevalence and risk factors of hypertension following nephrectomy in living kidney donors. Saudi J Kidney Dis Transpl. 2019 Jul-Aug;30(4):873-882. doi: 10.4103/1319-2442.265463. PMID: 31464244. [2] Einollahi B. Is proteinuria a common finding after kidney donation? Am J Transplant. 2014 May;14(5):1224-5. doi: 10.1111/ajt.12680. Epub 2014 Apr 2. PMID: 24698474. [3] Matas AJ, Rule AD. Risk of kidney disease after living kidney donation. Nat Rev Nephrol. 2021 Aug;17(8):509-510. doi: 10.1038/s41581-021-00407-5. Epub 2021 Feb 12. PMID: 33580211; PMCID: PMC8292201. [4] Ibrahim HN, Foley R, Tan L, Rogers T, Bailey RF, Guo H, Gross CR, Matas AJ. Long-term consequences of kidney donation. N Engl J Med. 2009 Jan 29;360(5):459-69. doi: 10.1056/NEJMoa0804883. PMID: 19179315; PMCID: PMC3559132. [5] Garg AX, Nevis IF, McArthur E, Sontrop JM, Koval JJ, Lam NN, Hildebrand AM, Reese PP, Storsley L, Gill JS, Segev DL, Habbous S, Bugeja A, Knoll GA, Dipchand C, Monroy-Cuadros M, Lentine KL; DONOR Network. Gestational hypertension and preeclampsia in living kidney donors. N Engl J Med. 2015 Jan 8;372(2):124-33. doi: 10.1056/NEJMoa1408932. Epub 2014 Nov 14. PMID: 25397608; PMCID: PMC4362716.
A- TRUE:
We identified incident hypertension as a risk factor in post-donation eGFR which merits aggressive preventive measures and careful management, as it is associated with cessation of the increase in eGFR following donation. Researchers found that, at 15 years, 8% of Caucasian non-donors and 9% of African American non-donors had hypertension compared with 23% of Caucasian donors and 42% of African American donors. Overall, kidney donation was associated with a 19% higher risk of hypertension. While researchers observed that African Americans had a greater risk (27%) than whites, the association between kidney donation and hypertension did not vary by race.
—Asch WS. Clin J Am Soc Nephrol. 2019;doi:10.2215/CJN.09650819. Holscher CM. Clin J Am Soc Nephrol. 2019;doi:10.2215/CJN.04020419.
B-True:
Three studies compared a total of 129 donors to 59 controls on 24-h urine protein, to determine if increases in proteinuria after donation were above that possibly attributable to normal ageing (Figure 1).45,58,60 Proteinuria appeared to be increased after donation in each of these three studies, although the CIs were wide. There was no evidence of statistical heterogeneity between these three studies, suggest- ing they could have been theoretically sampled from a common distribution (w2 0.51, P 1⁄4 0.78, I2 1⁄4 0%). Thus the results were mathematically pooled, to establish a more precise estimate. The 24-h urine protein was higher in donors compared to controls an average of 11 years after donation (controls 83 mg/day, donors 147 mg/day, weighted mean difference 66mg/day, and 95% CI 24–108). This difference increased with the time from the donation (Po0.001). –Garg, Amit X., et al. “Proteinuria and reduced kidney function in living kidney donors: a systematic review, meta-analysis, and meta-regression.” Kidney international 70.10 (2006): 1801-1810.
C-True:
Controlled studies were reviewed to determine if the initial decrement in GFR after nephrectomy was accompanied by a subsequent accelerated loss in GFR over that anticipated with normal ageing. There was no statistical heterogeneity between those where the average follow-up was at least 5 years after donation (w2 1.49, P 1⁄4 0.91, I2 1⁄4 0%) and these results were mathematically pooled (Figure 2).37,45,51,54,58,59 The pooled post-donation GFR was 10 ml/min (per 1.73 m2) lower in donors compared to controls (six studies totaling 189 controls and 239 donors; controls 96ml/min, donors 84 ml/min, weighted mean difference 10 ml/min, and 95% CI 6–15). The difference was similar across studies, irrespective of the time from the donation (P 1⁄4 0.2). –Garg, Amit X., et al. “Proteinuria and reduced kidney function in living kidney donors: a systematic review, meta-analysis, and meta-regression.” Kidney international 70.10 (2006): 1801-1810.
D-false: Self-reported diabetes was not significantly increased in donors when compared to healthy select controls eligible to be donors. A total of 1,029 kidney donors and 16,084 healthy controls from the HUNT study eligible for the donation from 1963 to 2008 were evaluated based on self-reported diabetes cases or on fasting glucose. — Haugen A, et al. Poster #360. Presented at: American Transplant Congress; May 30 – June 1, 2020.
E- TRUE: There is a small increased risk of gestational hypertension and preeclampsia in pregnancies that follow kidney donation. Kidney Disease Improving Global Outcomes (KDIGO) Clinical Practice Guideline (2017) and the 2015 American Society of Transplantation (AST) consensus conference statement recommend counselling kidney donors about this increased risk. There is no observed increase in fetal complications or eclampsia post-kidney donation. O’Keeffe et al. calculated risk pooled estimates of pregnancy-related outcomes from the Ontario and Norwegian studies [20•, 22•, 23]. The authors found that preeclampsia was twice as frequent in donors as in controls (5.9 vs. 3.1% of pregnancies) with a relative risk of 2.12 (1.06, 4.27). The relative risk for gestational hypertension was 2.27 (0.94, 5.36), low birth weight 1.70 (0.91, 3.16), and preterm birth 1.47 (0.78, 2.64) was not statistically significant between donors and non-donors. —Shah, Pratik B., Manpreet Samra, and Michelle A. Josephson. “Preeclampsia risks in kidney donors and recipients.” Current Hypertension Reports 20.7 (2018): 1-6.
Hypertension– yes
The incidence of hypertension following unilateral nephrectomy varied widely as it has been reported at 7%-75% (1, 2, 3). Moreso, a lot of studies with different years of follow up of studies has reported that one third of all kidney donors develop hypertension (4, 5) and a meta-analysis study has shown a weighted increase in 7mmHg for systolic and 5mmHg for diastolic in those that donate kidneys. (6). Among the risk that has been found to contributes to development of hypertension after kidney donation are pre-donation blood pressure, BMI, and age. Potential donor with any of the above risk will require lifestyle adjustment and close follow up
Proteinuria: yes
In many donors there is a modest increase in urine protein excretion after unilateral nephrectomy, the majority of whom have no evidence of accelerated GFR loss over time (7, 8)). In one study, five donors with low-grade proteinuria (mean 210 mg in a 24 hr urine collection) were more likely to have significant proteinuria 20 years or more after donation (>800 mg/day), although without significant loss of kidney function (9).
CKD yes
The proportion of donors that eventually developed proteinuria or GFR < 60ml/min after the surgery are more than the general population. In a retrospective study, it was reported that 10% of the donors exceed the 300mg/day proteinuria over a subsequent decade while about 12% developed GFR <60ml/min (10)
DM yes
Although, it is expected that donor with DM should not be allowed for kidney donor. In a study done comprising of 4014 living kidney donors and average age of follow up at 17.7 years, the incidence of DM after donation was reported as 2.4%, 7.4%, and 14.5% after 10, 20, and 30 years respectively (11). Donors with DM were observed to have a higher pre-donation BMI, glucose, serum creatinine and GFR, hence the presence of these risk factor should encourage a lifestyle adjustment following donation
Preeclampsia yes
In a Canadian cohort study that followed up 595 women (85 kidney donors and 510 non donor) for a median duration of 10.9 years and observational period of 20 years. The incidence of preeclampsia was higher among donors than non-donors (11% vs 5%) (12)
1)Anderson CF, Velosa JA, Frohnert PP, et al. The risks of unilateral nephrectomy: status of kidney donors 10 to 20 years postoperatively. Mayo Clin Proc 1985. 60: 367-74
2)Eberhard OK, Kliem V, Offner G, et al. Assessment of long-term risks for living related kidney donors by 24-h blood pressure monitoring and testing for microalbuminuria. Clin Transplant 1997; 11: 415-9
3)Miller IJ, Suthanthiran M, Riggio RR, et al. Impact of renal donation. Long-term clinical and biochemical follow-up of living donors in a single center. Am J Med 1985; 79: 201-8.
4)Fehrman-Ekholm I, Elinder CG, Stenbeck M, Tyden G, Groth CG. Kidney donors live longer. Transplantation 1997; 64: 976-8.
5)Ibrahim HN, Foley R, Tan L, et al. Long-term consequences of kidney donation. N Engl J Med 2009; 360: 459-69
6)Boudville N, Prasad GV, Knoll G, et al. Meta-analysis: risk for hypertension in living kidney donors. Ann Intern Med 2006; 145: 185-96.
7)Fehrman-Ekholm I, Dunér F, Brink B, et al. No evidence of accelerated loss of kidney function in living kidney donors: results from a cross-sectional follow-up. Transplantation 2001; 72: 444-9.
8) Garg AX, Muirhead N, Knoll G, et al. Donor Nephrectomy Outcomes Research (DONOR) Network. Proteinuria and reduced kidney function in living kidney donors: a systematic review, meta-analysis and meta-regression. Kidney Int 2006; 80: 1801-10
9)Goldfarb DA, Matin SF, Braun WE, et al. Renal outcome 25 years after donor nephrectomy. J Urol 2001; 166: 2043-7.
10)AX Garg, N Muirhead, G Knoll, RC Yang et al. Proteinuria and Reduce Kidney Function in Living Kidney Donors: A Systematic Review, Meta-analysis, Meta- regression. Int. Soc Nephrol. 2006; (70): 1801-10
11) H, N Ibrahim, D.M Berglund, S Jackson et al. Renal Consequence of Diabetes after Kidney Donation. AM J Transpl. 2107; (16): 3141-48
12)Amit X. Garg, Immaculate F. Nevis, Eric McArthur, eta l. Gestational Hypertension and Preeclampsia in Living Donor. New Eng j Med. 2015; 372: 2
references:
1}Amit X. Garg et al.Gestational Hypertension and preeclampsia in Living Kidney Donors. N Engl J Med 2015:372:124-133.
2}Anjay Rastogi et al. Blood pressure and Living Kidney Donors:A Clinical perspective. Transplant Direct 2019 oct:5[10].
3}Arther J Matas and Hassan N.Ibrahim.The unjustified Classification of Kidney Donors as Patients with CKD: Critique and recommendations.CJASN August 2013:8{8} 1406-1413
living donation is associated with an increased incidence of the following.
A. Hypertension;
Yes
Roughly a third of kidney donors develop hypertension after donation and risk factors for its development are similar to what is seen in the general population.
B. Proteinuria;
Yes
kidney donation resulted in small increases in urinary albumin, which increased with the time after donation.
C. CKD;
Yes
Ten years after nephrectomy, donors had a GFR that was 10 ml/
min lower compared to controls.
12% of donors developed a GFR less than 60 ml/min during
follow-up.
However, after the initial decrement in GFR from the nephrectomy, there was no evidence of an accelerated loss in GFR over that anticipated with normal aging.
D. DM;
No
The prevalence of diabetes was not significantly increased in kidney donors long after donation when compared to healthy patients, according to study findings presented at the American Transplant Congress.
E. Preeclampsia;
Yes
The absolute risk of pre-eclampsia increased from ~1%–3% pre-donation to ~4%–10% post-donation (comparable to the general population).
Reference;
1-by OA Sanchez · 2018 · Cited by 45 — After a mean (SD) of 16.6 (11.9) years of follow-up, 1126 (26.8%) donors developed hypertension and 894 were receiving anti-hypertensive ..
2-Proteinuria and reduced kidney function in livingkidney donors: A systematic review, meta-analysis,and meta-regression .A Housawi 1 and N Boudville1,6 for the Donor Nephrectomy Outcomes Research (DONOR) Network 7
3- Jun 8, 2020 — The prevalence of diabetes was not significantly increased in kidney donors long after donation when compared to healthy patients, .
4- Jun 18, 2022 — The absolute risk of pre-eclampsia increased from ~1%–3% pre-donation (lower than the general population) to ~4%–10% post-donation (comparable …
A….Hypertension
There no concluded or ascertain results
So we can say No with some considerations
Healthy, well-selected donors with no known risk factors, living kidney donation does not significantly predispose them to developing hypertension postdonation
But Certain risk factors, such as being African American or Hispanic, obese, or older, are associated with higher likelihoods of developing hypertension postdonation.
KDIGO Clinical Practice Guideline on the Evaluation and Follow-up Care of Living Kidney Donors states: “There is a need for well-designed studies to quantify the impact of live kidney donation on hypertension risk
On the other hand:
Kidney donation was independently associated with a 19% higher risk of hypertension (adjusted hazard ratio, 1.19; 95% confidence interval, 1.01 to 1.41; P=0.04); this association did not vary by race (interaction P=0.60)
In eight studies which reported GFR in categories,
12% of donors developed a GFR between 30 and 59ml/min (range 0–28%),
and 0.2% a GFR less than 30ml/min (range 0–2.2%).
In controlled studies urinary protein was higher in donors and became more pronounced with time (three studies totaling 59 controls and 129 donors; controls 83mg/day, donors 147mg/day, weighted mean difference 66mg/day, 95% confidence interval (CI) 24–108).
An initial decrement in GFR after donation was not accompanied by accelerated losses over that anticipated with normal aging
(six studies totaling 189 controls and 239 donors; controls 96ml/min, donors 84ml/min, weighted mean difference 10ml/min, 95% CI 6–15; difference not associated with time after donation
Kidney donation results in small increases in urinary protein. An initial decrement in GFR is not followed by accelerated losses over a subsequent 15 years.
The pooled incidence of proteinuria was 12% (95% CI, 8-16%
REFERENCES
Proteinuria and reduced kidney function in living kidney donors: A systematic review, meta-analysis, and meta-regression
Also
recommendations of a 2015 (AST) consensus statement and (KDIGO) clinical practice guidelines , OPTN policy requires informing donor candidates that the risk of ESKD after donation may exceed that of healthy nondonors with medical characteristics similar to living kidney donors
Additionally
Compared with controls, the risk of ESKD was higher among donors (with HR adjusted for age, sex, systolic blood pressure, smoking, and body mass index [BMI] of 11.4, 95% CI 4.4-29.6).
REFERENCES
Updated
Long term risk for kidney donors
D….DM
NO but with some considerations.
The risk factors for the development of T2DM in kidney donors is similar to the general population
Living donor with family history of DMT1 has higher risk to develop DM and lesser extent without statistically significant DMT2 other risk factors
BMI > 30
Male
Age>45
REFERENCES
Diabetes after Kidney Donation H. N. Ibrahima,
E….Gestational hypertension or preeclampsia
Yes
The risk of this outcome was higher among donors than among nondonors (11% vs. 5%; odds ratio for donors, 2.4; 95% confidence
interval [CI], 1.2 to 5.0; P = 0.01).
Each component of the primary outcome was also more common among donors (odds ratio, 2.5 for gestational hypertension and 2.4 for preeclampsia).
The two groups did not differ significantly with respect to other secondary maternal or fetal outcomes.
REFERENCES
Gestational Hypertension and Preeclampsia in Living Kidney Donors Amit X. Garg,
A. True ( in a study, the risk of hypertension is 20% higher in kidney donors who were followed for up to 27 years post-donation compared to healthy matched non-donors).
Asch WS.CJASN October 2019, 14 (10) 1427-1429.
B. True ( in a study, 6% developed proteinuria after a median of 18 years post-donation).
Ibrahim HN, Foley RN, Reule SA, Spong R, Kukla A, Issa N, et al. Renal Function Profile in White Kidney Donors: The First 4 Decades. J Am Soc Nephrol. 2016; 27: 2885–2893.
C. True ( in a study, 35.6% had GFR below 60 at a median time of 9.2 years from donation) Ibrahim HN, Foley RN, Reule SA, Spong R, Kukla A, Issa N, et al. Renal Function Profile in White Kidney Donors: The First 4 Decades. J Am Soc Nephrol. 2016; 27: 2885–2893.
D. True (The risk of diabetes mellitus in donors with pre-diabetes is higher than for a healthy donor with normal glucose metabolism).
Renal Consequences of Diabetes After Kidney Donation.American Journal of Transplantation.2017; 17: 3141–3148.
E. True ( in a study, over a median follow-up of 11 years, 11% develop preeclampsia post-donation).
Lentine KL, Segev DL.Understanding and Communicating Medical Risks for Living Kidney Donors: A Matter of Perspective. J Am Soc Nephrol 28: 12–24, 2017
Living donation is associated with increased incidence of HTN, proteinuria, CKD and preeclampsia
A meta-analysis included observational studies of living kidney donors with follow up duration of one year or more in comparison with nondonor controls showed that donors had higher diastolic BP with no difference in systolic BP between donors and controls, authors explained it b better selection and matching of donors and control groups in more recent studies. (1)
This meta-analysis also showed that donors have higher risk for CKD and ESKD than nondonors with no evidence that living donors had higher risk for T2DM. (1)
Another meta-analysis showed that donation is associated with decreased GFR and increased proteinuria with gradually increasing rate of microalbuminuria and proteinuria at 5-year intervals after kidney donation (2)
A meta-analysis of studies evaluating rate of pregnancy complications among female donors showed that living donation is associated with significant higher risk of preeclampsia and is expected to complicate 7.4% of gestations. (3)
(1)O’Keeffe LM, Ramond A, Oliver-Williams C, Willeit P, Paige E, Trotter P, Evans J, Wadström J, Nicholson M, Collett D, Di Angelantonio E. Mid-and long-term health risks in living kidney donors: a systematic review and meta-analysis. Annals of internal medicine. 2018 Feb 20;168(4):276-84.
(2)Li SS, Huang YM, Wang M, Shen J, Lin BJ, Sui Y, Zhao HL. A meta-analysis of renal outcomes in living kidney donors. Medicine. 2016 Jun;95(24).
(3)Bellos I, Pergialiotis V. Risk of pregnancy complications in living kidney donors: A systematic review and meta-analysis. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2022 Jan 3.
its the summary of this week’s journal club Hypertension: correct -study showed that after 10y time post-donation, donor tend to develop hypertension 10% more nondonor matched group this percentage increase in the Prescence of some risk factors like higher BP before donation, African American and Hispanic ethnicity, obesity and elderly, proteinuria: correct CKD: correct a systematic review and meta-analysis (level of evidence I) evaluating Proteinuria and reduced kidney function in living kidney donors: after Kidney donation, small increases in proteinuria with an average 24 h urine protein was 154 mg/day which is higher than control. only 10% of donors developed proteinuria ≻ 300 mg/day and this hyperfiltration wasn’t associated with any evidence of accelerated loss of GFR. · Regarding eGFR, even with initial loss of GFR, during long-term follow up there is no major loss in eGFR but this initial loss of GFR wasn’t followed by accelerated loss of eGFR.12 % has GFR 30 – 59 ml/min, 0.2% has GFR ≤30. regarding ESRD: The cause of ESRD among donors was found to be mainly due to an immunological cause (SLE, ANCA vasculitis, SLE, glomerulonephritis) which may be explained by the biological relation between donor and recipients DM: wrong -across-sectional study (level of evidence III) The prevalence of type 2 DM in kidney donors after the donation is the same prevalence in the general population preeclampsia: correct a retrospective study that included 2 Adequately matched groups evaluating Gestational Hypertension and Preeclampsia in Living Kidney Donors showed that: gestational HT & PE was more in LKD than non-donors but other maternal & fetal outcomes didn’t differ between donors & non-donors, without maternal or perinatal death. references 1- Sanchez OA, Ferrara LK, Rein S, et al. Hypertension after kidney donation: Incidence, predictors, and correlates. Am J Transplant 2018; 18:2534. 2- Muzaale AD, Massie AB, Wang MC, et al. Risk of end-stage renal disease following live kidney donation. JAMA 2014; 311:579. 3- Lam NN, Lentine KL, Garg AX. End-stage renal disease risk in live kidney donors: what have we learned from two recent studies? Curr Opin Nephrol Hypertens 2014; 23:592. 4- LaPointe Rudow D, Hays R, Baliga P, et al. Consensus conference on best practices in live kidney donation: recommendations to optimize education, access, and care. Am J Transplant 2015; 15:914.
Hypertension is true incidence level 10% post transplant after 10year
Proteinuria is true with incidence 34%
CKD is true
DM is wrong
Preeclampsia is true with incidence 4%
living donation can increase the risk of hypertension, proteinuria, and low incidence of ESKD in addition to the increased risk of post-donation preeclampsia and pregnancy-induced hypertension in female donors so all correct accept D , not associated with increased risk of DM
Level 3 evidence
Reterospective case control study where cases and controls of previous studies which fulfilled the criteria were cumulated and analysed through a theoretical model.
this is a population-based analysis of a large cohort with no RCT so it fit level 2 of evidence
Wadia Elhardallo
2 years ago
Please summarise this article in your own words
Ø The study estimated the potential loss of life and the lifetime cumulative risk of end-stage renal disease (ESRD) from live kidney donation. Participants 40-year-old live kidney donors of both sexes and black/white race, underwent live donor nephrectomy.
Ø Main outcome and measures Potential remaining life years lost, quality-adjusted life years (QALYs) lost and added lifetime cumulative risk of ESRD from donation.
Ø Overall 0.532–0.884 remaining life years were lost from donating a kidney. This was equivalent to 1.20%–2.34% of remaining life years (The risk was higher in male and black individuals. The study showed that 1%–5% of average-age current live kidney donors might develop ESRD as a result of nephrectomy. Most of the loss of life was predicted to be associated with chronic kidney disease (CKD) not ESRD. Most events occurred 25 or more years after donation.
Ø Live kidney donation may reduce life expectancy by 0.5–1 year in most donors. The development of ESRD in donors may not be the only measure of risk as most of the predicted loss of life predates ESRD. The study identifies the potential importance of following donors and treating risk factors aggressively to prevent ESRD and to improve donor survival
What is the level of evidence provided by this article?
Level 2
Mohamed Ghanem
2 years ago
The long-term hazards are also thought to be low, particularly in low-risk donors who have undergone thorough screening. However, according to recent findings, organ donation may raise the chance of developing end-stage renal disease (ESRD) and may also increase cardiovascular mortality.
Patients who donate a kidney may be more likely to develop chronic kidney disease (CKD), which is indicated by proteinuria or a poor glomerular filtration rate (GFR) of less than 60 mL/min/1.73 m2.
Additionally, despite being screened, some donors will subsequently acquire diabetes mellitus, and they may be more likely to develop hypertension as well.
These diseases may hasten the loss of kidney function and raise the risk of ESRD
The long-term hazards are also thought to be low, particularly in low-risk donors who have undergone thorough screening. However, according to recent findings, organ donation may raise the chance of developing end-stage renal disease (ESRD) and may also increase cardiovascular mortality.
Patients who donate a kidney may be more likely to develop chronic kidney disease (CKD), which is indicated by proteinuria or a poor glomerular filtration rate (GFR) of less than 60 mL/min/1.73 m2.
Additionally, despite being screened, some donors will subsequently acquire diabetes mellitus, and they may be more likely to develop hypertension as well.
These diseases may hasten the loss of kidney function and raise the risk of ESRD
This study demonstrates that donation may reduce life expectancy in average-age donors by 1%–2%, with a large portion of the mortality being linked to CKD rather than ESRD.
The study also looked at risk variables including smoking, obesity, and biological ties to the receiver that may be linked to greater risks of mortality and ESRD
Level II
CARLOS TADEU LEONIDIO
2 years ago
Please summarise this article in your own words
The reduction in life expectancy and the risk of developing end-stage renal disease are the main concerns of a living kidney donor. Therefore, this study attempted to estimate the potential loss of life and cumulative risk of end-stage renal disease (ESRD) from donation.
This study demonstrated a shortening of donor lifespan of approximately 1%-2%, which is probably not seen in other studies due to the short follow-up period (< 20 years). However, increased mortality and decreased quality-adjusted life years (QALY) were associated with Chronic Kidney Disease (CKD) and not with End-stage Kidney Disease (ESRD), perhaps because this transition takes many years.
Another important piece of evidence was that detection of risk factors (hypertension, diabetes mellitus, and so on) and prompt intervention can help prevent end-stage renal disease and improve donor survival.
What is the level of evidence provided by this article?
This is a level 2 study.
Dalia Ali
2 years ago
Introduction
Nearly 30 000 live donor kidney transplant surgeries
are performed throughout the world each year.1 The benefits to the recipients are substantial in terms of improved life expectancy and quality of life compared with dialysis or deceased donor transplantation.
Recent reports however show that there is some increase in risk of end-stage renal disease (ESRD) from donation and possibly an increase in cardiovascular mortality.5 6 Patients who donate a kidney may be at greater risk of developing chronic kidney disease (CKD) as defined by a low glomerular filtration rate (GFR) of <60 mL/ min/1.73 m2 or proteinuria.7 Furthermore, some donors will develop diabetes mellitus at a later date despite being screened and may be at higher risk of developing hypertension.
Knowing the long-term risks associated with kidney donation is important to potential donors and their providers. The focus of existing studies has been on the increase in ESRD risk resulting from kidney donation. In this study we show that donation potentially shortens life in average-age donors by about 1%–2%. This analysis shows that short-term studies (<20 years) even with appropriate normal controls are not likely to detect an adverse effect on survival.
Death during the CKD health state accounted for most of the projected increase in mortality and reduction in QALYs. Intuitively this makes some sense given that the transition from CKD to ESRD can be over many years and that progressive kidney disease is associated with graded increases in mortality. The mechanism by which low glomerular filtration rate CKD is associated with an increase in cardiovascular and all-cause mortality rate is not completely known.
It is possible that the lower glomerular filtration rate CKD as a result of donating a kidney in an ideal donor may well be different from CKD that is associated with proteinuria or diabetes mellitus. However, lower mortality risks associated with CKD were explored in the model and the results showed only a modest reduction in the percentage of total life years and QALYs projected to be lost. Although loss of life from CKD was higher compared with life lost from the ESRD health state, there were differences based on race and sex. About 78% of the loss of all QALYs from donation was associated with CKD in white female, whereas the loss was 58% in black male.
This model incorporated the probability that some donors will develop diabetes mellitus, hypertension and proteinuria at a later date, and these would impact on health (overall survival and progression to ESRD) as they do in the general population. The model could have been simplified if these risk factors for CKD and ESRD were not included in the model, but this would not reflect reality. Recent longer term observational studies have found that some donors develop diabetes mellitus and hypertension, despite being absent at the time of donation, and that these factors are subsequently responsible for ESRD.
The baseline analysis also showed that white males suffer greater added long-term ESRD risks from donation than would be anticipated. For white male the added risk of an ESRD event was 1 for every 28 donors. For black male the risk was 1 in 22. One would have expected the added risk of ESRD in white male to be less than half the added risk in black male from what is known in the general population.
The relationship between loss of remaining life years (and QALYs) and added risk of ESRD in donors is not straightforward. For example, although nearly 3.5% of white male donors are predicted to develop ESRD as a result of donation, only 0.094 QALYs or 0.43% of total remaining QALYS are lost as a result of ESRD. Calculating loss of remaining life years and QALYs helps put the risk of donation into context with other activities. The loss of life from live kidney donation is projected to be far less than smoking or mild obesity . Despite the higher initial perioperative mortality, live partial liver donation may be less risky over the long run compared with live kidney donation.
Ideally a prediction equation could be developed as was recently published for the incidence of ESRD in non-donors with differing baseline characteristics. However it was not the purpose or ability of this study to give a precise estimate of lifetime ESRD for individual donors with multiple conditions. The analysis shows that younger donors have greater added risks of ESRD and potential life years lost; however, the percentage loss of life was somewhat less compared with older cohorts. The effect of smoking and diabetes mellitus had large effects on overall survival and in lifetime risks of ESRD in donors and non-donors
The analysis suggests that counselling and interventions to reduce weight and smoking cessation are more important to both donor and non-donor and less of an argument to deny donation. Having a non-biological relationship to the recipient was associated with lower risks; however, the majority of donors are related.Donors with diabetes mellitus were at very high added risks of ESRD and death. It is interesting to point out that a 40-year-old white female with diabetes mellitus, who is otherwise well, has about the same added risk of ESRD and percentage loss of life years as a current ideal 40-year-old black male donor.
There are limitations to modelling future events. We rely on the observed rates of ESRD over 15 years in actual donors and a theoretical matched cohort to calculate lifetime outcomes.Life expectancy and the cumulative incidences of diabetes mellitus and ESRD are increasing. Using historic mortality and disease incidence rates to make accurate future lifetime projections is a significant limitation; however, similar modelling studies are used to inform current practice.
More information is required before we can truly estimate the impact of live kidney donation. Given the need for large numbers of patients and controls and long term follow-up, this risk may never be accurately measured for all age, race, sex and those with minor medical abnormalities. Given the above, estimating lifetime ESRD rates in non-donors may not be the best or only metric to inform the risk of donation.11 Greater efforts to put risk into context for potential donors in the face of uncertainty for any one individual donor. Asking donors whether they may be willing to give up between 0.5 and 1 year of life may be a better way to convey risk than giving them an estimate of their lifetime risk of ESRD. In addition the study identifies the potential importance of following donors and treating risk factors aggressively to prevent ESRD and to improve donor survival.
Level 2
Mohammed Sobair
2 years ago
Introduction :
Nearly 30 000 live donor kidney transplant surgeries are performed throughout the world each year.
The benefits to the recipients are substantial in terms of improved life expectancy and quality of life compared with dialysis or deceased donor transplantation.
The risks to the donors are generally felt to be small to modest, with a low postoperative mortality (approximately 3.1 deaths per 10 000 operations).
some increase in risk of end-stage renal disease (ESRD) from donation and possibly an increase in cardiovascular mortality.
Patients who donate a kidney may be at greater risk of developing chronic kidney disease (CKD) as defined by a low glomerular filtration rate (GFR) . Aim of the study
were to estimate the potential loss of life as well as the added lifetime risk of ESRD in average-risk kidney donors. Methods Model description
A USA-based Markov model was used to examine the risk of ESRD in a population of non-donors and doors. Patient involvement in study designs.
There was no patient recruitment or participation in this study but rather the study relied on prior published analyses. Target population :
The base case cohorts were 40-year-old patients of both sexes and white/black race from the USA. This is the mean age of live donors (median age 38) and for whom there are recent published estimates of 15-year cumulative risks of ESRD in non-donors and donors. Main outcome measures
The health outcome of interest was remaining years of life (undiscounted).
Lifetime cumulative incidence of ESRD was also calculated. Intervention effects
Donors in the study underwent unilateral nephrectomy. It is assumed that the nephrectomy results in a loss of GFR, and this loss of function would increase the probability of transitioning from a normal (GFR ≥60mL/min/1.7 60mL/min/1.73m2 ) to CKD. Time horizon
The time horizon for remaining life years and QALYS was lifetime. However, for ESRD, the cumulative incidence was truncated at age 90 in keeping with other studies. Results Baseline analysis
Differences in survival between the cohorts became apparent after 20 years or more after donation.
the remaining life years lost from donation ranged between 0.532 years for white female and 0.884 years for black female donors.
The per cent loss of life was highest in black male donors.
The per cent loss of life varied from 1.20% for white female to 2.34% for black male.
The per cent loss of total QALYs varied from 0.76% for white female to 1.51% for black male
Live kidney donation was associated with an added risk of ESRD especially among those of male sex and black race.
The added lifetime cumulative risk of ESRD varied from 1.135% in white female to 4.645% in black male (
More than 50% of all ESRD events in donors occurred 25 years or more after donation. The added ESRD even more in black male than white ones.
Donors were projected to spend 50%–85%more time with an isolated low glomerular filtration rate CKD (CKD not associated with diabetes mellitus or proteinuria) compared with non-donors.
younger patients lost more potential years of life and had potentially greater risks of ESRD given longer exposure to reduced kidney function.
However on a percentage basis, loss of life was greater in older compared with younger donors.
Life expectancies were markedly reduced and lifetime risks of ESRD increased for cohorts who were smokers or had diabetes mellitus.
Obese patients were also at increased risk but less so compared with smokers and those with diabetes mellitus. Surprisingly the absolute loss of life years was slightly less in donors who were obese or smoked compared with donors without these conditions.
Non-biological relationship to the recipient was associated with much lower loss of life years and risk of ESRD compared with those who were biologically related. Discussion:
In this study we show that donation potentially shortens life in average-age donors by about 1%–2%. This analysis shows that short-term studies .
study also explored risk factors that can be associated with higher rate, death and ESRD such as smoking, obesity and biological relationship to the recipient.
Although loss of life from CKD was higher compared with life lost from the ESRD health state, there were differences based on race and sex. About 78% of the loss of all QALYs from donation was associated with CKD in white female, whereas the loss was 58% in black male. Given these findings, risk factor detection (hypertension, diabetes mellitus and so on) and prompt intervention could help prevent ESRD and improve donor survival.
The baseline analysis also showed that white males suffer greater added long-term ESRD risks from donation than would be anticipated. For white male the added risk of an ESRD event was 1 for every 28 donors. For black male the risk was 1 in 22. One would have expected the added risk. Limitation of the study:
Study rely on the observed rates of ESRD over 15 years in actual donors and a theoretical matched cohort to calculate lifetime outcomes.
Using historic mortality and disease incidence rates to make accurate future lifetime projections is a significant limitation.
The study was an analysis of US donors, whereas the non-donor control population included US and international populations.
The results may not be generalised to live kidney donors from other countries where population ESRD rates are much lower.
There are many variables and transition rates included in this model and addressing uncertainty in each or combinations of variables would require a much longer paper.
The key uncertainties explored were the cumulative risks of developing ESRD and the increased mortality associated with CKD states.
The model did not include multiple stages of CKD.
Level of evidence 11.
Abdullah Raoof
2 years ago
Q4- Lifetime risks of kidney donation: a medical decision analysis
1- Please summarise this article in your own words?
Abstract
This study estimated the potential loss of life and the lifetime cumulative risk of end-stage renal disease (ESRD) from live kidney donation. The risk was higher in male and blackindividuals.
The study showed that 1%–5% of average-age current live kidney donors might develop ESRD as a result of nephrectomy. The added risk of ESRD resulted in a loss of only 0.126–0.344 remaining life years. Most of the loss of life was predicted to be associated with chronic kidney disease (CKD) not ESRD.
Most events occurred 25 or more years after donation. Reducing the increased risk of death associated with CKD had a modest overall effect on the per cent loss of remaining life years (0.72%–1.9%) and QALYs (0.58%–1.33%).
Smoking and obesity reduced life expectancy and increased overall lifetime risks of ESRD in non-donors. However the percentage loss of remaining life years from donation was not very different in those with or without these risk factors.
Conclusion Live kidney donation may reduce life expectancy by 0.5–1 year in most donors. The development of ESRD in donors may not be the only measure of risk as most of the predicted loss of life predates ESRD. The study identifies the potential importance of following donors and treating risk factors aggressively to prevent ESRD and to improve donor survival.
Introductin
The risks of HT, proteinuria, ESRD to the donors are generally small to modest, with a low postoperative
mortality (approximately 3.1 deaths per 10 000 operations).
The long-term risks are small especially in low-risk donors. New reports show that there is some increase in risk of end-stage renal disease (ESRD) from donation and possibly an increase in cardiovascular mortality. Donors may be at risk of developing chronic kidney disease (CKD) as defined by a low glomerular filtration rate (GFR) of <60 mL/ min/1.73 or proteinuria. some donors will develop diabetes mellitus at a later date and may be at higher risk of developing hypertension.
CKD is associated with an increase in risk of progression to ESRD and an increase in predialysis mortality.
Discussion
Donors should be counseled about the long-term risks associated with kidney dona tion
this study show s that donation potentially shortens life in aver age- age donors by about 1%–2%.
This analysis shows that short-term studies (<20 years) even with appropriate normal controls are not likely to detect an adverse effect on survival. Although ESRD is associated with very high mortality rates, a significant per cent of the loss of life was associated with CKD not ESRD. The study also explored risk factors that can be associated with higher rates of death and ESRD such as smoking, obesity and biological relationship to the recipient.
The per cent of patients modelled to be alive at 20 years post nephrectomy for an average-age white male donor was only 0.2% lower than a non-donor
This study shows that some donors will develop DM, HT and proteinuria at a later date, and these would impact on health (overall survival and progression to ESRD) as they do in the general population.
NEW long term observational studies have found that some donors develop DM and HT , and that these factors are subsequently responsible for ESRD.
The baseline analysis also showed that white males suffer greater added long-term ESRD risks from donation than would be anticipated. For white male the added risk of an ESRD event was 1 for every 28 donors. For black male the risk was 1 in 22.
The analysis shows that younger donors have greater added risks of ESRD and potential life years lost;but , the percentage loss of life was somewhat less compared with older cohorts. The effect of smoking and diabetes mellitus had large effects on overall survival and in lifetime risks of ESRD in donors and non-donors.
Donors with DM were at very high added risks of ESRD and death.
2- What is the level of evidence provided by this article?
Level of evidence 2
Sahar elkharraz
2 years ago
risks of kidney donation: a medical decision analysis
This study focus on survival rate of living donor post donation and risk factors leading to developing of end stage renal disease which are indirect risk of increase mortality rate. Where they do fallow up to life donor more than 15 years post donation.
The study shows decrease life expectancy to 0.5 to 1 year in comparison to non donors.
it shows little decline of estimate glomerular filtration rate with increase of age to less than 60 ml /min and increase risk of cardiovascular disease and death.
Markov model description which focus on risk factors which lead to CKD in patients who donate and compare those with non donation.
Shows donor who develop diabetes mellitus and hypertension after years from donation are associated with chronic kidney disease and ESRD in comparison to non donor but increase mortality rate in both donor and non donor are similar who had history of diabetes and hypertension and CKD because CKD risk of cardiovascular disease and increase mortality rate.
Risk factors of smoking and obesity in living donation despite good selection of healthy donor at time of donation are at high risk of hypertension and diabetes post donation and risk of chronic kidney disease and cardiovascular risk and death.
Also risk of proteinuria with hypertension more in donor rather than non donor with date.
Risk of CKD more in white female 78% and in black male around 58%.
mortality increase in CKD patients more in patients with ESRD.
The study shows the risk appeared to accelerate in white male after 25–30 years of follow-up. in comparison to black male.
The effects of diabetes and smoking on donor are high in increase risk of cardiovascular disease and reduce life expectancy in comparison to obesity donor.
living donor are less mortality in peri operative stage because improving in laparoscopically technique in removal kidney.
The analysis of study shows young donor are at high risk of reduce life expectancy.
It’s important to counselling regarding cessation of smoking and reduce weight and annually screening for diabetes and hypertension.
Level 3
Sahar elkharraz
2 years ago
risks of kidney donation: a medical decision analysis
This study focus on survival rate of living donor post donation and risk factors leading to developing of end stage renal disease which are indirect risk of increase mortality rate. Where they do fallow up to life donor more than 15 years post donation.
The study shows decrease life expectancy to 0.5 to 1 year in comparison to non donors.
it shows little decline of estimate glomerular filtration rate with increase of age to less than 60 ml /min and increase risk of cardiovascular disease and death.
Markov model description which focus on risk factors which lead to CKD in patients who donate and compare those with non donation.
Shows donor who develop diabetes mellitus and hypertension after years from donation are associated with chronic kidney disease and ESRD in comparison to non donor but increase mortality rate in both donor and non donor are similar who had history of diabetes and hypertension and CKD because CKD risk of cardiovascular disease and increase mortality rate.
Risk factors of smoking and obesity in living donation despite good selection of healthy donor at time of donation are at high risk of hypertension and diabetes post donation and risk of chronic kidney disease and cardiovascular risk and death.
Also risk of proteinuria with hypertension more in donor rather than non donor with date.
Risk of CKD more in white female 78% and in black male around 58%.
mortality increase in CKD patients more in patients with ESRD.
The study shows the risk appeared to accelerate in white male after 25–30 years of follow-up. in comparison to black male.
The effects of diabetes and smoking on donor are high in increase risk of cardiovascular disease and reduce life expectancy in comparison to obesity donor.
living donor are less mortality in peri operative stage because improving in laparoscopically technique in removal kidney.
The analysis of study shows young donor are at high risk of reduce life expectancy.
It’s important to counselling regarding cessation of smoking and reduce weight and annually screening for diabetes and hypertension.
This evidence level 2
rindhabibgmail-com
2 years ago
A. true.
B. true
C. true
D. true
E. true
Abhijit Patil
2 years ago
Objective
This study estimated the potential loss of life and the lifetime cumulative risk of end-stage renal disease (ESRD) from live kidney donation.
Design Markov medical decision analysis. Setting USA. Participants 40-year-old live kidney donors of both sexes and black/white race. Intervention Live donor nephrectomy. Main outcome and measures Potential remaining life years lost, quality-adjusted life years (QALYs) lost and added lifetime cumulative risk of ESRD from donation.
Results
Overall 0.532–0.884 remaining life years were lost from donating a kidney. This was equivalent to 1.20%–2.34% of remaining life years (or 0.76%–1.51% remaining QALYs).
The risk was higher in male and black individuals.
The study showed that 1%–5% of average-age current live kidney donors might develop ESRD as a result of nephrectomy.
The added risk of ESRD resulted in a loss of only 0.126–0.344 remaining life years.
Most of the loss of life was predicted to be associated with chronic kidney disease (CKD) not ESRD.
Most events occurred 25 or more years after donation.
Reducing the increased risk of death associated with CKD had a modest overall effect on the per cent loss of remaining life years (0.72%–1.9%) and QALYs (0.58%–1.33%).
Smoking and obesity reduced life expectancy and increased overall lifetime risks of ESRD in non-donors.
However the percentage loss of remaining life years from donation was not very different in those with or without these risk factors.
Conclusion
Live kidney donation may reduce life expectancy by 0.5–1 year in most donors.
The development of ESRD in donors may not be the only measure of risk as most of the predicted loss of life predates ESRD.
The study identifies the potential importance of following donors and treating risk factors aggressively to prevent ESRD and to improve donor survival.
Limitation of study:
The study relied on the observed rates of ESRD over 15 years in actual donors and a theoretical matched cohort to calculate lifetime outcomes.
Life expectancy and the cumulative incidences of diabetes mellitus and ESRD are increasing. Using historic mortality and disease incidence rates to make accurate future lifetime projections is a significant limitation
analysis of only US donors
The results may not be generalized to live kidney donors from other countries
The key uncertainties explored were the cumulative risks of developing ESRD and the increased mortality associated with CKD states.
Lower risks of developing diabetes mellitus and proteinuria were also explored in ideal donors.
The model did not include multiple stages of CKD.
Level of evidence
Level III
Alyaa Ali
2 years ago
The study were conducted to estimate the potential loss of life as well as the added lifetime risk of ESRD in average risk kidney donors.
Target population: the base case cohorts were 40 year-old patients of both sexes and white/black race from the USA.
This study showed that donation potentially shortens life in average age donors by about 1% to 2% . The risk was higher in male and black individuals.
This analysis showed that short term studies < 20 years even with appropriate normal controls are not likely to detect an adverse effect on survival.
The study showed that 1% to 5% of average age current live donors might develop ESRD as a result of nephrectomy
A significant percent of the loss of life was associated with CKD not ESRD. The study showed that smoking and obesity were associated with higher rates of death and ESRD.
Conclusion: live kidney donation may reduce life expectancy by 0.5 – 1 year in most donors. The development of ESRD in donors may not be the only measure of risk as most of the predicted loss of life predates ESRD .so the donors should be followed up and any risk factors should be considered and treated to prevent ESRD and to improve donor survival.
Level of evidence 2
Last edited 2 years ago by Alyaa Ali
Filipe prohaska Batista
2 years ago
This is a retrospective cohort study – level IIb.
It used a model called Markov medical decision analysis using the American position at age 40 including gender or ethnicity. The intention of the study is to define whether there is a difference in the prognosis of living donors who underwent nephrectomy based on sex or ethnicity. The main objectives were to assess years of potential life lost, adjusted loss of years lost, and cumulative risk of end-stage renal disease.
The analysis was performed in comparison with a population with the same characteristics as the donor, having the healthy behavior of a potential donor.
The results showed that the difference in survival in the cohorts only occurred after 20 years after donation. Men of black ethnicity had the worst survival rates, including considering QUALYs. The same occurs with ESRD, where most cases occurred within 25 years or more of donation.
Even in different sexes, black women (1.74%) are at higher risk than white men (1.39%) when compared to black men (1.9%). In other analyses, young people were at greater risk of donating. Diabetes and smoking are other risk factors, the former being the worst. Obesity may have some related potential, but it is inferior to the previous two.
This study showed that the loss of life potential ranges from 1 to 2%, being more related to chronic kidney disease and not an end-stage renal disease. These risks were different depending on ethnicity (whites 1 in 28 / blacks 1 in 22). This study suggests smoking cessation is associated with weight loss in those with a BMI greater than 30.
Ban Mezher
2 years ago
The benefit of renal transplantation is well known as it improve survival of the recipients, but the life long donor risk supposed to be small in low risk donors after screening. But recent studies show that increased risk of ESRD & CVD in donors & some may develop HT or DM years after donation which increase the risk of eGFR reduction.
This meta-analysis of systemic review found :
Short term studies(<20 years) didn’t detect adverse effects of donation on survival.
High percentage of death was associated CKD more than ESRD.
Smoking, obesity & biological relation to recipient are risk factors that increase risk of death & ESRD development.
CKD death was the most frequent cause of mortality & loss of QoL which can be explain by progression of CKD to ESRD take many years.
78% of loss of all QoL after donation was associated with white females.
Some donor can develop DM & HT years after donation despite absence of these diseases at donation which can increase risk of ESRD.
Long term risk of ESRD in white was high due to high life expectancies in white & acceptance criteria for white is more lenient than black donors.
Life years lost from donation was larger than life years gained from colorectal carcinoma screening. in average risk persons.
Life long risk of ESRD was high in young donors but % loss of life was lower in older cohorts.
DM & smoking have the greatest effect on ESRD development in donors & non donors, but the effect of obesity was lower than smoking & DM.
Council & intervention of weight reduction & smoking cessation are more important for donors & non donors & less argument to decline donation.
Non related donors have less risk of ESRD development.
Limitations of the study:
Using theoretical matched non donors.
increased incidence of DM & ESRD over years.
using historic mortality & disease incidence to estimate life time projections( major limitation).
Donor population was from US while non donors were from US & international.
These studies didn’t use multiple stages of CKD.
Under-estimation of net loss of life years from nephrectomy.
wide range of age was available from donor cohort while in analysis use only donors with 40 years in mean.
Family history of ESRD of biological related donors were not available.
Level 1 study
amiri elaf
2 years ago
# Please summarise this article in your own words
*The aim of the study:
To estimate the potential loss of life and the lifetime cumulative risk of (ESRD) from live kidney donation.
# Introduction:
*About 30 000 live donor kidney transplant surgeries are done throughout the world per year,
* The benefits of kidney transplant surgeries to the recipients are substantial in terms of improved life expectancy and quality of life compared with dialysis or deceased donor transplantation.
*The risks to the donors are generally felt to be small to modest, with a low postoperative mortality *Patients who donate a kidney may be at greater risk of developing (CKD) as defined by a low (GFR) of <60 mL/ min/1.73 m2 or proteinuria, some donors will develop diabetes mellitus at a later date despite being screened and may be at higher risk of developing hypertension.
* These conditions could accelerate the loss of kidney function and increase the risk of ESRD.
#Methods
#Model description
*A USA-based Markov model was used to examine the risk of ESRD in a population of non-donors and donors.
#The following are the key assumptions for the model:
*The incidence of ESRD rates are higher in donors compared with non-donors.
*In both donors and non-donors ESRD will be associated with high mortality rates.
* Donor and non-donors transition through a CKD state for at least 1 year before developing ESRD.
* As the ESRD rates are high in donors compared with non-donors, so there have been
an increase in the rate of transition to and time spent in CKD states.
* Nephrectomy in donors will quantitatively reduce overall patient kidney function.
(donors will have a greater risk of falling below a GFR threshold of 60 mL/min/1.73 m2 compared with non-donors).
* Cohorts are assumed to be free of HTN, DM and proteinuria at donation, but they are risky to developing these conditions whether they donate or not, and these will impact patient survival and loss of kidney function in both donors and non-donors.
*CKD states will be associated with higher mortality rates as in the general population.
* Model transition rates from normal to CKD states could be empirically derived to reproduce observed 15-year cumulative incidence rates for ESRD in donors and non-donors and can be used to subsequently project lifetime cumulative risks of ESRD.
# Results:
*Overall 0.532–0.884 remaining life years were lost from donating a kidney. This was equivalent to 1.20%–2.34% of remaining life years (or 0.76%–1.51% remaining QALYs).
*The risk was higher in male and black individuals.
The study showed that 1%–5% of average-age current live kidney donors might develop ESRD as a result of nephrectomy. The added risk of ESRD resulted in a loss of only 0.126–0.344 remaining life years. Most of the loss of life was predicted to be associated with chronic kidney disease (CKD) not ESRD.
*Most events occurred 25 or more years after donation. Reducing the
increased risk of death associated with CKD had a modest overall effect on the per cent loss of remaining life years (0.72%–1.9%) and QALYs (0.58%–1.33%).
*Smoking and obesity reduced life expectancy and increased overall lifetime risks of ESRD in non-donors. However the percentage loss of remaining life years from donation was not very different in those with or without these risk factors.
# The strength and limitation:
*The study projects the long-term risk of donating a kidney, including loss of life and the added risk of end-stage renal failure.
* These findings help quantify and communicate risk to potential donors and convey the importance of lifelong follow-up in actual donors.
* The study uses evidence of over 15 years of follow up in actual live kidney donors and healthy controls.
*The ability to predict lifetime outcomes from 15- year follow-up in donors of all ages and medical conditions is a limitation.
# Conclusion
Live kidney donation may reduce life expectancy by 0.5–1 year in most donors. The
development of ESRD in donors may not be the only measure of risk as most of the predicted loss of life predates ESRD. The study identifies the potential importance of following donors and treating risk factors aggressively to prevent ESRD and to improve donor survival.
# What is the level of evidence provided by this article?
It is cohort study, prospective study level 2.
mai shawky
2 years ago
Summary
· Many studies suggested that donors are at higher risk of proteinuria, development of CKD, HTN, DM, and cardiovascular mortality when compared to non-donors.
· Risk factors for those complications are male gender and black races.
· There is a definite risk of decrease life by Donation, but still of little significance (about 0.5-1 year).
· Also risk of ESRD is present especially in obese, smoker and biologically related donor.
· Conclusion
· However, it is still a minimal risk and the procedure should continue.
· Healthy Lifestyle as weight reduction, smoking cessation and regular follow up can alter this outcome
· Level of evidence: II
hussam juda
2 years ago
· There is some evidence that there is some increase in risk of ESRD from donation and possibly an increase in cardiovascular mortality.
· Donors could be at greater risk of developing CKD as defined by a low GFR of <60mL /min / 1.73 m2 or proteinuria
· Some donors also can develop DM and have higher risk of HTN post donation Objectives of the study
· estimate the potential loss of life as well as the added lifetime risk of ESRD in average-risk kidney donors
Methods Model description
the key assumptions for the model:
· ESRD rates are increased in donors compared with non-donors
· ESRD in both donors and non-donors will be associated with high mortality rates
· Donor and non-donors transition through a CKD state for at least 1year before developing ESRD
· The assumed there must have been an increase in the rate of transition to and time spent in CKD states
· Post nephrectomy, donors will have a greater risk of falling below a GFR threshold of 60mL/min/1.73m2 compared with non-donors.
· At donation, cohorts are free of DM, HTN, and proteinuria. But they are at risk to develop thise conditions, even if they are not donors
· CKD states will be associated with higher mortality rates as in the general population
· CKD progression to ESRD is increased by age
Target population
The base case cohorts were 40-year-old patients of both sexes and white/black race from the USA
Results
· The differences in survival between the cohorts became apparent after 20 years or more after donation
· loss of life varied from 1.20% for white female to 2.34% for black male.
· Live kidney donation was associated with an added risk of ESRD especially among those of male sex and black race
· The added lifetime cumulative risk of ESRD varied from 1.135% in white female to 4.645% in black male
· More than 50% of all ESRD events in donors occurred 25 years or more after donation
· The added ESRD events tended to occur earlier in black male compared with white male
· In a sensitivity analysis, the added cumulative risks of developing ESRD were predicted to be lower in the ‘ideal’ cohort especially for white male and female compared with the base case analysis
· Donors were predicted to live 50%–85%more time with low GFR CKD without DM or proteinuria compared with non-donors
· Donors with DM or smokers have reduced Life expectancies and increased lifetime risks of ESRD
· Obese donors also had more risk but less than smokers and diabetics
· Strangely the absolute loss of life years was slightly less in obese or smoking donors compared with donors without these conditions.
· Diabetic donors had the greatest loss of life years and increased risk of ESRD
· Non-biological related donors had much lower loss of life years and risk of ESRD than biologically related
CONCLUSION
· Donation potentially shortens life in average-age donors by about 1%–2%
· Although ESRD is associated with very high mortality rates, a significant per cent of the loss of life was associated with CKD not ESRD
· Smoking and obesity may have a role in the mortality and progression to ESKD
· Larger numbers of patients and controls and long term follow-up are needed to accurately measure the risk for all age, race, sex and those with minor medical abnormalities
Limitation of the study:
· Follow up of donors for 15 years not enough to predict lifetime outcome
· The study was an analysis of US donors, whereas the non-donor control population included US and international populations
· The results cannot be widely applicable to live kidney donors worldwide where incidence of ESRD is different
· The model did not include multiple stages of CKD
· Since donors eventually have a greater risk of entering into a more advanced CKD state, this analysis may have underestimated the overall net loss of life years from nephrectomy
· Author assumed that the relative risks between white and black of both sexes with a biological relationship were the same
What is the level of evidence provided by this article?
observational longitudinal cohort study evidence level 2
Mu'taz Saleh
2 years ago
The number of living donation in increasing with time , the effect of transplantation on the patient and the subsequent improving in the quality of life and increase life expectancy is well studied ,
in this study they interested to know the long term effect on donation in the donors such as ESRD , CKD , protienurea , HTN … etc
results :
decreasee in life expectancy : apparent after 20 years or more after donation
highest in black male donors
Risk of ESRD : the absolute and per cent loss of life years and QALYs from donation were only modestly lower compared with the base case analysis .
Risk of CKD : Donors spend 50%–85% more time with an isolated low glomerular filtration rate CKD compared with non-donors.
Risk of HTN : The risk of hypertension was found to be higher in donors compared to non donors,
Risk of protienurea : Albuminuria occur more commonly after donation when compared to healthy non donors
Living donation is associated with an increased incidence of the following. A. Hypertension : yes B. Proteinuria : yes C. CKD : yes D. DM : no E. Preeclampsia : yes
Eusha Ansary
2 years ago
Summary:
This study was conducted to estimate the cumulative risk of ESRD and risk of loss of life post kidney donation. And include living kidney donors aged 40 years and follow up more than 15 years.
This study showed:
-Remaining years of life and QALYs: Loss of 0.5-0.8 year from life (equivalent to 1.2-2.3% of remaining life).
-Donation potentially reduced life by 1-2% in a 40 year old donor.
-Males and African-Americans showed higher risk of life loss.
-Loss of life is mostly due to CKD.
-ESRD incidence: 1-5%. Added risk of ESRD reduced 0.1-0.3years from remaining life. More in black males and less in white females
-50% ESRD occurred more than 25 years post-donation.
-DM, smoking, obesity, and organ donation were associated with higher risk of life loss and ESRD.
Level of evidence: level 2
Theepa Mariamutu
2 years ago
Risk for donors after nephrectomy is small provided, they are of low risk and are followed regularly for any complications or new development of diabetes or hypertension.
Studies have shown that kidney donors are at high risk of development of CKD, ESRD and cardiovascular complications while can develop HTN, DM on long term too.
Study has shown the 15 years and lifetime risk of developing ESRD in potential non donors that candidates with minor medical comorbidities, male, and those of black race are at higher risk.
This cohort study evaluating the possible death and the added lifetime risk of ESRD in average risk kidney donors.
Markov model was used to evaluate the risk of ESRD in non-donors and donors.
This model supposed that.
· ESRD will be more associated with donors than non-donors and that both candidates with ESRD will have high mortality rate.
· Both candidates will go through CKD before reaching ESRD
· Nephrectomy will be associated with low GFR threshold of 60mL/min/1.73m2 compared with non-donors.
· Candidates are supposed to be disease free and can be at high risk of developing DM ,HTN , or proteinuria later on if donated or if did not donate along with their impact on survival and renal function
· CKD cases have high mortality risks
· Transition rates from normal to CKD states
The model can derive to reproduce observed 15-year cumulative incidence rates for ESRD in donors and non-donors.
The study included data published before on the estimates of 15-year cumulative risks of ESRD in non-donors and donors for 40 years old candidates of both sexes and races.
QALYs were calculated and lifetime cumulative incidence of ESRD was also calculated.
Result:
· Survival variation between the cohorts was noticed after 20 years or more after donation.
· The per cent loss of life was highest in black male donors.
· The percentage loss of life ranged from 1.20% for white female to 2.34% for black male.
· The % loss of total QALYs varied from 0.76% for white female to 1.51% for black male.
· The added lifetime cumulative risk of ESRD ranged from 1.135% in white female to 4.645% in black male.
· Most ESRD events in donors happened 25 years or more after donation.
· Donors experienced 50%–85%more time with an isolated low eGFR CKD compared with non-donors.
· Overall percentage loss of remaining life years of 1.39%, 0.72%, 1.9% and 1.74% for white male, white female, black male, and black female, respectively.
· Young were subjected to more loss of years of life and higher liability of ESRD development due to longer time of exposure to low eGFR, on the other hand on percentage loss of life was greater in older donor,
· ESRD and lesser life expectancy were associated with smoking, obesity and DM mean while obese smoker donors had little less risk than non-obese non-smoker donors.
· Diabetic donors had the greatest loss of life years and increased risk of ESRD. Life loss and ESRD were higher in biologically related donors to recipients.
This study showed that donation can shorten life in average age donors by 1%–2% and short-term studies even with suitable controls are unable to detect an adverse effect on survival. CKD not ESRD was associated with significant percentage of life loss. Risk factors associated with increased risk of ESRD and death as smoking, obesity and DM were assessed. Meanwhile it is not clear whether donation has a significant impact on death risk or not. The possible percentage to be alive after 20 y of donation for average aged white donor is 0.2% less than matched non donor candidate.
The model overestimated the lifetime ESRD predictions in non-donors. White males had long-term ESRD higher risks from donation than would be supposed could be due to longer life expectancy. Death due to donation is much less than death due to smoking or obesity. Live partial liver donation seems to be less risky over time than live renal donation although the former has higher perioperative mortality risk . Smoking and diabetes mellitus had great impact on overall survival and in lifetime risks of ESRD in donors and non-donors. The effects were less in obese donors compared with donors who were smoking or had diabetes mellitus.
Limitation as ESRD and DM risk are increasing.
· There were many variables and transitions included in the model but CKD stages were not included.
· The ability to predict lifetime prognosis from 15- year follow-up of donors of all ages and medical
· conditions is a limitation.
· Informing the donors about the possibility of giving up between 0.5 and 1year of life may be a better way to explain the risk than giving them an estimate of their lifetime risk of ESRD
· Long term follow up of donors is essential to avoid risks
Level 2 cohort study
Shereen Yousef
2 years ago
summary of the article
Nearly 30 000 live donor kidney transplant surgeries are performed throughout the world each year.
in low-risk donors long-term risks are felt to be small and on very long time .
Recent reports showed there is some increase in risk of ESRD and cardiovascular mortality from donation .
Kidney donors are at greater risk of developing chronic kidney disease (CKD) as defined by a low glomerular filtration rate (GFR) of <60mL/ min/1.73m2 or proteinuria.
some donors may become diabetic or hypertensive later date despite being screened which might accelerate the loss of kidney function and increase predialysis mortality.
▪︎Key assumptions for the study model
–high incidence of ESRD in donors compared with non-donors.
– ESRD is associateed with high mortality rates In all groups.
– CKD state for at least 1 year before developing ESRD in both groups .
– Nephrectomy in donors will quantitatively reduce overall patient kidney function.
– as kidney function declines over time in most individuals, donors will have higher risk of lower eGFR below threshold of 60 mL/min/1.73 m2 compared with non-donors.
-Cohorts are assumed to be free of hypertension, diabetes mellitus and proteinuria at donation, and risk of developing these conditions whether they donate or not, and these will impact patient survival and loss of kidney function in both donors and non-donors.
-Given that some individuals may be at higher or lower risks of diabetes mellitus and proteinuria, smoke or are obese, we examined these in additional sensitivity analyses.
-Diabetes mellitus in non-donors would follow the same pattern (increasing rates with age) as in the general population.
– CKD states will be associated with higher mortality rates as in the general population.
– Model transition rates from normal to CKD states could be empirically derived (by working backwards) to reproduce observed 15-year cumulative incidence rates for ESRD in donors and non-donors and can be used to subsequently project lifetime cumulative risks of ESRD.
▪︎The base case cohorts were 40-year-old patients of both sexes and white/black race from the USA.
for whom there are recent published estimates of 15-year cumulative risks of ESRD in non-donors and donors.
▪︎Main outcome measures
-outcome of interest was remaining years of life .
-life years were scaled by measures of quality and discounted at a 3% rate of time preference to calculate QALYs.
-Lifetime cumulative incidence of ESRD was also calculated.
-The lifetime estimates of ESRD were found to be higher in non-donors than published estimates, since this model incorporated the possibility that some participants might develop diabetes mellitus and proteinuria.
– Ideal non-donors had lower incidence of diabetes mellitus, proteinuria and rates of transition to CKD to match projected lifetime ESRD risks rather than calibrating to 15-year ESRD risks.
-Non-donors were assumed to have lifetime cumulative ESRD risks of 0.43% , 0.29% , 1.00% and 0.85% for white male, white female, black male and black female, respectively.
– mortality associated with CKD is an important driver of life years lost.
▪︎Results
-Differences in survival between the cohorts became apparent after 20 years or more after donation.
-the remaining life years lost from donation ranged between 0.532 years for white female and 0.884 years for black female donors while the highest percent was in black male donors.
-The percent loss of life varied from 1.20% for white female to 2.34% for black male. The percent loss of total QALYs varied from 0.76% for white female to 1.51% for black male.
-The study showed that 1%–5% of average-age current live kidney donors might develop ESRD.
-The added risk of ESRD resulted in a loss of only 0.126–0.344 remaining life years.
-Most of the loss of life was predicted to be associated with (CKD) not ESRD.
-Death during the CKD health state accounted for most of the projected increase in mortality and reduction in QALYs
-Smoking and obesity and biological relationship to the recipient are risk factors associated with reduced life expectancy and increased overall lifetime risks of ESRD in non-donors.
– Live kidney donation may reduce life expectancy by 0.5–1 year in most donors.
-The relationship between loss of remaining life years (and QALYs) and added risk of ESRD in donors is not straightforward.
-The analysis suggests that counselling and interventions to reduce weight and stop smoking are more important to both donor and non-donor and less of an argument to deny donation.
-Having a non-biological relationship to the recipient was associated with lower risks; however, the majority of donors are related
More information is required before we can truly estimate the impact of live kidney donation.
Given the need for large numbers of patients and controls and long term follow-up, estimating lifetime ESRD rates in non-donors may not be the best or only metric to inform the risk of donation.
▪︎What is the level of evidence provided by this article?
The level of evidence II
Ahmed Omran
2 years ago
A. Correct: risk of hypertension in donors compared to non donors is 5-20%. B. Correct : post donation proteinuria occurs with incidence of11.5-34% . C. Correct: post donation CKD incidence is 10% ;relative risk of ESRD is eight times more than controls. D. False :no evidence of increased post donation DM. E .Correct: Post donation preeclampsia has incidence of 11% compared to 5% in non donors; with incidence of gestational hypertension of 5 % in donors compared to 2 % for non donors.
Muntasir Mohammed
2 years ago
Please summarise this article in your own words
Introduction Around 30000 kidney donations is done yearly worldwide. The expected benefit is improving survival and quality of life for the recipients. However, there is a risk for the donor although it is small. With post operative mortality of around 3 per 10000 surgeries. On the long term also, the risk is estimated to be low, but some recent reports showed that risk of ESRD is increased. The objectives of this study were to estimate the potential loss of life as well as the added lifetime risk of ESRD in average- risk kidney donors.
Methods Model description A USA-based Markov model was used to examine the risk of ESRD in a population of non-donors and donors. Target population The base case cohorts were 40-year-old patients of both sexes and white/black race from the USA. This is the mean age of live donors (median age 38) and for whom there are recent published estimates of 15-year cumulative risks of ESRD in non-donors and donors.
Main outcome measures The health outcome of interest was remaining years of life.
Intervention effects Donors in the study underwent unilateral nephrectomy. It is assumed that the nephrectomy results in a loss of GFR, and this loss of function would increase the probability of transitioning from a normal (GFR ≥60 mL/min/1.73 m2) kidney function heath state to CKD. Results Differences in survival starts to appear after 20 years or more from donation. The remaining life years lost from donation ranged between 0.532 years for white female to 0.884 years for black female donors. The per cent loss of life was highest in black male donors. The per cent loss of life varied from 1.20% for white female to 2.34% for black male. The per cent loss of total QALYs varied from 0.76% for white female to 1.51% for black male. Those with diabetes has more loss than others. The added lifetime cumulative risk of ESRD varied from 1.135% in white female to 4.645% in black male. This translated to one added ESRD event for every 88 white female donors or one added ESRD event for every 22 black male donors. Discussion This study showed that the remaining life lost because of donation range from 1-2%. It is higher in black male and lowest in white female. If we compared this with life lost due to smoking and mild obesity the late are costing more. Compared with live part of liver donation, despite higher perioperative mortality in liver donation 1.7 per 1000 versus 0.31 per 1000 kidney donations, there is no long-term life loss in the liver donors. This study also highlighted the importance of long time follow up, as the risk of CKD and ESRD appears after 25years. This means that studies with shorter duration will easily missed this risk. Limitations 1. Limitation of modelling future events. 2. We rely on the observed rates of ESRD over 15 years in actual donors and a theoretical matched cohort to calculate lifetime outcomes. 3. Life expectancy and the cumulative incidences of diabetes mellitus and ESRD are increasing. 4. Using historic mortality and disease incidence rates to make accurate future lifetime projections. however, 5. The study was an analysis of US donors, whereas the non-donor control population included US and international populations.
What is the level of evidence provided by this article?
Level 11
Marius Badal
2 years ago
Based on this article, it provides information about the lifetime risk of kidney donation. The study was conducted in the United States using Marlov model to examine the risk of ESRD in a population of non-donor and donors. The model key information used are: 1) ESRD are found more frequently in donors than non-donors 2) Once both groups have ESRD they have high mortality rate 3) The transitional stage in donor and non-donors to CKD to ESRD may be a timeline of 1 year. 4) Kindy donation with time will lead to decrease in kidney function and the donor will be at increased risk of kidney failure or decrease GFR.
Based on the study, it was found that:
1) Donations reduce life by 1-2 % in a 40-year-old donor
2) Male patients and African American are at a higher risk to loss of life.
3) CKD is the main reason for loss of life
4) After 25 years post donation there is 50% chance of having ESRD.
Certain risk factors have associated risk of increase ERSD and as such life loss and are as follows:
1) DM
2) Obesity
3) Smoking
The limitation of this study was that it lacks control group, only a small number of donors were included, the follow-up was a short time and different stages of CKD were not included.
The level of evidence in the study was 3
Manal Malik
2 years ago
1-Summary ofLifetime risks of kidney donation: a medical decision analysisAim of this study were estimate the potential loss of life as well as the added life time risk of ESRD in average age risk kidney donors .
Methods:
Model description AUSA- based Markov, model was used to examine the risk of ESRD in a population of non donors and donor.
There was no patients in this study but rather than study relied on prior published analysis.
The target population were 40 years old patients of both sex and white /black race from USA.
This study ,main outcome measure health out come of life and incidence of ESRD in donors.
All donors in the study had unilateral nephrectomy which result in a loss of GFR and subsequent develop of CKD .
Analysis, design and outcomes
Primary outcome of the same population of healthy potential donors were the change of their remaining life years ,QALYS and development of ESRD.
Donors were assumed to have 15 years cumulative ESRD risk of 0.34 ,0.15 % 0.96 % and 0.59% for white male ,white female ,black male and black female .
Isolated CKD (no proteinuria ,nor DM) in donors compared with non-donors was not associated with an increase in mortality.
Others sensitivity analysis include age at donation ,smoking status ,higher BMIA new onset DM and biological relationship to recipient were explored.
Result
Live kidney donation was associated with an added risk of ESRD especially among those of male sex and black race .
More than 50% of all ESRD events in donors occurred 25 years or more after donation.
Younger had greater risk of ESRD .
Loss of life was greater in older compared with younger donors.
The absence loss of life years was slightly less in donors who were obese or smoke compared with donors without these condition.
Discussion
In this study we show that donation potentially shorten life in average age donors 1% -2%.
Shorten of the time of this analysis(<20years) are unlikely to detect and decrease effect on survival .
Based on current literature it is unclear whether is a significant risk of death from donation but studies had small numbers .
Many of these risk factors develop years after donation .
Short term follow up of kidney donors may be inadequate obesity and smoking are risk factors that might develop after donation.
2-What is the level of evidence provided by this article?
level 2
Zahid Nabi
2 years ago
The burden of ESRD is ever growing and organ shortage is a world wide problem.Convincing a living donor is another issue faced by all of us in our daily practice.The question and anxiety of potential donors is always to know what kind of risks donation would pose to them and how it is going to effect their future life.
Kiberd and collaegues used a USA-based Markov model to examine the risk of ESRD in a population of non-donors and donors.
The following are the key assumptions for the model:
ESRD rates are increased in donors compared with non-donors
ESRD in both donors and non-donors will be associat- ed with high mortality rates.
Donor and non-donors transition through a CKD state for at least 1 year before developing ESRD.
Since ESRD rates are increased in donors compared with non-donors, we assumed there must have been
an increase in the rate of transition to and time spent
in CKD states.
Nephrectomy in donors will quantitatively reduce overall patient kidney function. Given that kid- ney function declines over time in most individu- als, donors will have a greater risk of falling below a GFR threshold of 60 mL/min/1.73 m2 compared with
non-donors.
Cohorts are assumed to be free of hypertension, dia- betes mellitus and proteinuria at donation. However they are at risk of developing these conditions wheth- er they donate or not, and these will impact patient
survival and loss of kidney function in both donors
and non-donors. Given that some individuals may be at higher or lower risks of diabetes mellitus and proteinuria, smoke or are obese, we examined these in additional sensitivity analyses. Diabetes mellitus in non-donors would follow the same pattern (increas- ing rates with age) as in the general population even though absolute rates might be lower (if initially screened to be negative).
CKD states will be associated with higher mortality rates as in the general population, but the magnitude of this effect was examined in additional sensitivity
analyses.
Model transition rates from normal to CKD states could be empirically derived (by working backwards) to reproduce observed 15-year cumulative incidence rates for ESRD in donors and non-donors and can be
used to subsequently project lifetime cumulative risks of ESRD. CKD in non-donors would follow the same pattern (increasing rates with age) as in the general population but at overall lower rates.
Main outcome and measures
Potential remaining life years lost,
quality-adjusted life years (QALYs) lost
and added lifetime cumulative risk of ESRD from donation.
STRENGTH AND WEAKNESS
The study projects the long-term risk of donating a kidney, including loss of life and the added risk of end-stage renal failure.
These findings help quantify and communicate risk to potential donors and convey the importance of lifelong follow-up in actual donors.
The study uses evidence of over 15 years of follow- up in actual live kidney donors and healthy controls.
The ability to predict lifetime outcomes from 15- year follow-up in donors of all ages and medical
conditions is a limitation.
RESULTS
Overall 0.532–0.884 remaining life years were lost from donating a kidney.
This was equivalent to 1.20%–2.34% of remaining life years (or 0.76%–1.51% remaining QALYs).
The risk was higher in male and black individuals. The study showed that 1%–5% of average-age current live kidney donors might develop ESRD as a result of nephrectomy.
The added risk of ESRD resulted in a loss of only 0.126–0.344 remaining life years.
Most of the loss of life was predicted to be associated with chronic kidney disease (CKD) not ESRD.
Most events occurred 25 or more years after donation. This is an observational longitudinal cohort study with population data as controls. Therefore, this article provides level 2 evidence. (Thanks Dr Sharma)
Hamdy Hegazy
2 years ago
Please summarize this article in your own words
This study was conducted in the USA to estimate the cumulative risk of ESRD and risk of loss of life post kidney donation. Included subjects: living kidney donors aged 40 years. Follow up: more than 15 years. Methods: reviewing published studies and analysis using Markov model. Results: 1- Remaining years of life and QALYs: Loss of 0.5-0.8 year from life (equivalent to 1.2-2.3% of remaining life). 2- Donation potentially reduced life by 1-2% in a 40 year old donor. 3- Males and African-Americans showed higher risk of life loss. 4- Loss of life is mostly due to CKD. 5- ESRD incidence: 1-5%. Added risk of ESRD reduced 0.1-0.3years from remaining life (maximum for black males and least for white females). 6- 50% ESRD occurred more than 25 years post-donation. DM, smoking, obesity, and organ donation were associated with higher risk of life loss and ESRD. Limitations: 1- Small numbers of donors in the included studies. 2- short-term follow-up (<30 years). 3- Lack of controls. 4- The study group was US donors, while control population included international population. 5- Multiple stages of CKD were not included.
What is the level of evidence provided by this article?
Level III evidence
l of evidence (LOE) Description
Level I
Evidence from a systematic review or meta-analysis of all relevant RCTs (randomized controlled trial) or evidence-based clinical practice guidelines based on systematic reviews of RCTs or three or more RCTs of good quality that have similar results.
Level II
Evidence obtained from at least one well-designed RCT (e.g. large multi-site RCT). Level III Evidence obtained from well-designed controlled trials without randomization (i.e. quasi-experimental).
Level IV
Evidence from well-designed case-control or cohort studies. Level V Evidence from systematic reviews of descriptive and qualitative studies (meta-synthesis).
Level VI
Evidence from a single descriptive or qualitative study.
Level VII
Evidence from the opinion of authorities and/or reports of expert committees.
Ramy Elshahat
2 years ago
A retrospective case-control study (level III) in which there was no patient recruitment or participation in this study instead the study relied on prior published analyses evaluating quality-adjusted life years lost related to donation and the cumulative lifetime risk of end-stage renal disease (ESRD) in 40years old kidney donors of both sexes and white/black race from the USA. Based on the hypothesis that: 1] The risk of CKD is higher after donation due to a decrease in renal mass 2] complications related to donation like hypertension and DM which potentiate the risk of deterioration. Methods: No patient recruitment or participation in this study instead the study relied on prior published analyses OF 40-year-old life kidney donors of both sexes, black and white races. All patients Were followed for 15 years after kidney donation and then compared to a controlled cohort. Results:
risk of ESRD more in donor group around 1-5 % in comparison to nondonor group.
complications related to donation occur late after around 25 years of donation.
complications more common in Males and blacks
Most of the loss of life was linked to chronic kidney disease, not ESKD.
life expectancy was reduced by 0.5 -1 year (quality-adjusted life years) in comparison to the non-donor control group.
smoking and obesity were risk factors for chronic kidney disease progression.
Tahani Ashmaig
2 years ago
Lifetime risks of kidney donation: a medical decision analysis _____________________€ ☆Introduction ▪︎The risks to the kidney donors after surgery are small to modest, with a low postoperative mortality. ▪︎The long-term risks are also presumed to be small especially in low-risk donors who are adequately screened. ☆Risks of kidney donation:
1.CKD (low GFR of <60mL/ min/1.73m2 or proteinuria) which may progress to ESRD 2. Increase in cardiovascular mortality. 3. DM 4. Hypertension. ▪︎Donors with minor medical abnormalities, men and individuals of black race had greater 15-year and lifetime risks of ESRD. ☆The objectives of the study To estimate the potential loss of life as well as the added lifetime risk of ESRD in average-risk kidney donors. ☆Results: ▪︎Overall 0.532–0.884 remaining life years were lost from donating a kidney. ▪︎The risk was higher in male and black individuals. ▪︎The study showed that 1%–5% of average-age current live kidney donors might develop ESRD as a result of nephrectomy. ▪︎The added risk of ESRD resulted in a loss of only 0.126–0.344 remaining life years. ▪︎Most of the loss of life was predicted to be associated with CKD not ESRD. ▪︎Most events occurred 25 or more years after donation. Reducing the increased risk of death associated with CKD had a modest overall effect on the per cent loss of remaining life years (0.72%–1.9%) and QALYs (0.58%–1.33%). ▪︎Smoking and obesity reduced life expectancy and increased overall lifetime risks of ESRD in non-donors. However the percentage loss of remaining life years from donation was not very different in those with or without these risk factors. ☆Strength of this study: 1.The study projects the long-term risk of donating a kidney, including loss of life and the added risk of end-stage renal failure. 2.The findings help quantify and communicate risk to potential donors and convey the importance of lifelong follow-up in actual donors. 3.The study uses evidence of over 15 years of follow-up in actual live kidney donors and healthy controls ☆Limitations: The ability to predict lifetime outcomes from 15- year follow-up in donors of all ages and medical conditions. ☆Conclusion ▪︎Live kidney donation may reduce life expectancy by 0.5–1 year in most donors. ▪︎The development of ESRD in donors may not be the only measure of risk as most of the predicted loss of life predates ESRD. ▪︎The study identifies the potential importance of following donors and treating risk factors aggressively to prevent ESRD and to improve donor survival.
Mohamed Saad
2 years ago
Lifetime risks of kidney donation: a medical decision analysis.
Patients who donate a kidney may be at greater risk of developing chronic kidney disease (CKD) as defined by a low glomerular filtration rate (GFR) of <60 ml/min/1.73 m2 or proteinuria which might lead to ESRD and high risk of death.
The aim of this study to estimate the potential loss of life as well as the added lifetime risk of ESRD in average-risk kidney donors.
Method.
No patients concluded in this study but the study relied on prior published analyses, targeted 40-year-old patients of both sexes and white/black race from the USA and to examine the risk of ESRD in a population of non-donors and donors they used Markov model (which figure out transition from the normal health state through other health states).
Result.
– The remaining life years lost from donation ranged between 0.532 years for white female and 0.884 years for black female donors.
– The percent loss of life varied from 1.20% for white female to 2.34% for black male (The per cent loss of life was highest in black male donors).
– The percent loss of total QALYs varied from 0.76% for white female to 1.51% for black male.
– The added lifetime cumulative risk of ESRD was 4.645% in black male which much higher than white female.
– More than 50% of all ESRD events in donors occurred 25 years or more after donation (but occurred earlier in black men).
– An overall percent loss of remaining life years of 1.39%, 0.72%, 1.9% and 1.74% for white male, white female, black male and black female, respectively.
-Younger patients lost more potential years of life and had potentially greater risks of ESRD given longer exposure to reduced kidney function but loss of life was greater in older compared with younger donors.
– Life expectancies were markedly reduced and lifetime risks of ESRD increased for smokers and obese cohorts and donors with DM.
Conclusion:
Live kidney donation may reduce life expectancy by 0.5–1 year in most donors. The development of ESRD in donors may not be the only measure of risk(there are many co-morbidities) as most of the predicted loss of life predates ESRD.
Still living kidney donation is the best modality for treating ESRD patients worldwide for the recipient , community and cost wise, so it is considered so important to follow up kidney donors and control the associated risk factors to decrease the risk of CKD and improving the total outcomes.
Level of evidence:3
Wael Jebur
2 years ago
To project the 15 years and lifetime cardiovascular mortality and ESKD risk in Kidney donors, this study was conducted. As it was increasingly reported, adverse outcomes, particularly cardiovascular mortality and risk of ESKD, related to kidney donation is gaining potential. Initially, the common believe was, kidney donation impart minor risk of CVD mortality and ESKD.
The followings are the main hypothesis to test:
1]The risk of CKD {and therefore ESKD} is higher secondary to renal mass reduction which will be culminating in a GFR below 60 ml/min.
2] those donors are prone to develop hypertension and DM later post donation which would potentiate the risk of deterioration entailed by the mentioned confounders.
3] The age-related inherent diminution of GFR is suspected to be precipitous and detrimental in kidney donors as their baseline GFR is subnormal in the first place.
Methods:
All patients with 15 years follow up after kidney donation compared to a controlled cohort. By using Markov medical decision analysis. 40-year-old life kidney donors of both sexes, black and white races.
Intervention is live donation nephrectomy.
Results:
This study showcased the risk of 1-5 % of ESKD kidney donors’ group.
Most events reported after 25 years of donation.
Male and black are at increased risk of adverse events.
Most of loss of life was linked to chronic kidney disease, not the ESKD.
life expectancy was reduced by 0.5 -1 year in comparison to non-donor control group.
smoking and obesity were risk factors for chronic kidney disease progression.
This study points up the importance of follow up the donors, closely addressing their risk factors and managing thereof.
It’s a retrospective study with level of evidence 3
Reem Younis
2 years ago
. Please summarise this article in your own words
-The recent reports show that there is some increase in risk of end-stage
renal disease (ESRD) from donation and possibly an increase in cardiovascular
mortality.
-Patients who donate a kidney may be at greater risk of developing chronic
kidney disease , diabetes mellitus and hypertension.
– Donor with minor medical abnormalities, men and individuals
of black race had greater 15-year and lifetime risks of ESRD.
– objectives of this study were to estimate the potential loss of life as well as the added lifetime risk of ESRD in average- risk kidney donors.
– Although ESRD is associated with very high mortality rates, a significant per cent of the loss of life was associated with CKD not ESRD.
– The per cent of patients modelled to be alive at 20 years post nephrectomy for an average-age white male donor was only 0.2% lower than a non-donor .
– About 78% of the loss of all QALYs from donation was associated with CKD in white female, whereas the loss was 58% in black male.
– The baseline analysis showed that white males suffer greater added long-term ESRD risks from donation than would be anticipated.
– The loss of life from live kidney donation is projected to be
far less than smoking or mild obesity .
– The live partial liver donation may be less risky over the long run compared
with live kidney donation.
-Despite a higher postoperative mortality with partial live liver donation, kidney donation results in more loss of life when adding in the long-term impact.
– The life years lost from donation are greater than the life years gained from colorectal cancer screening in an average-risk person.
-The younger donors have greater added risks of ESRD and potential life years lost; however, the percentage loss of life was somewhat less compared with older cohorts.
-The effect of smoking and diabetes mellitus had large effects on overall survival and in lifetime risks of ESRD in donors and non-donors. The effects were less in obese donors compared with donors who were smoking or had diabetes mellitus. – Donors with diabetes mellitus were at very high added risks of ESRD
and death. A40-year-old white female with diabetes mellitus, who is otherwise well, has about the same added risk of ESRD and percentage loss of life years as a current ideal 40-year-old black male donor.
– Since donors eventually have a greater risk of entering into a more
advanced CKD state, this analysis may have underestimated the overall net loss of life years from nephrectomy.
-There is no data on family history of ESRD in the non-biological-related donors. What is the level of evidence provided by this article?
Level 2
Amit Sharma
2 years ago
Please summarise this article in your own words
Renal donors have low post-operative mortality, but some studies have shown increased risk of developing GFR <60 ml/min or proteinuria, diabetes mellitus and hypertension and ESRD.
The study estimated the loss of life and risk of developing ESRD in living kidney donors of age 40 years over 15 years follow-up, by considering previously published studies and utilizing Markov model.
The outcomes measured included:
a) Remaining years of life and QALYs: Loss of 0.532-0.884 year from life (equivalent to 1.2-2.34% of remaining life). Risk of life-loss was higher in males and African-Americans. Loss of life is mostly due to CKD.
b) Lifetime cumulative ESRD incidence: 1-5%. Added risk of ESRD reduced 0.126-0.344 years from remaining life (maximum for black males and least for white females). More than 50% ESRD occurred more than 25 years post-donation.
Smoking, obesity, diabetes mellitus and biologically related organ donation were associated with increased lifetime risks of ESRD and loss of life. Risk associated with smoking and obesity in non-donors for decreased life and increased ESRD is more than the risk associated with donation in the donors.
The study showed that donation potentially reduced life by 1-2% in a 40 year old donor. Loss of life from living kidney donation is far less than that due to smoking or obesity. So, counselling for weight reduction and smoking cessation should be done and relevant interventions undertaken in this regard.
Limitations: The studies included had small numbers, short-term follow-up (<30 years) and lacked highly scrutinized controls. The study cohort was US donors, while the non-donor control population included international populations. The model did not include multiple stages of CKD. The donors included in the analysis were 40-year-old, while the data available is form a wide range of donors.
What is the level of evidence provided by this article?
The aim of this study is to demonstrate the living donor’s:
1- potential loss of life
2- loss of lifetime cumulative risk of ESRD
this study follows the Makov medical decision analysis design
following are the key assumptions for the model:
ESRD rates are increased in donors compared with non-donors
ESRD in both donors and non-donors will be associated with high mortality rates.
transition through a CKD state for at least 1 year before developing ESRD.
donors will have a greater risk of falling below a GFR threshold of 60 mL/min/1.73 m2 compared with non-donors.
risk of developing hypertension- DM- proteinuria whether they donate or not, and these will impact patient survival and loss of kidney function in both donor and non donor
Results;
Differences in survival between the cohorts became apparent after 20 year
The per cent loss of total QALYs varied from 0.76% for white female to 1.51% for black male.
Live kidney donation was associated with an added risk of ESRD especially among those of male sex and black race.
The per cent loss of life attributed to ESRD in relation to total remaining years of life varied between 0.29% for white female and 0.88% for black male
Assuming the added proportion of time spent with isolated low GFR CKD had no increase in all-cause mortality rate
younger patients lost more potential years of life and had potentially greater risks of ESRD given longer exposure to reduced kidney function. However on a percentage basis, loss of life was greater in older compared with younger donors.
lifetime risks of ESRD increased for cohorts who were smokers or had diabetes mellitus. Obese patients were also at increased risk but lesser
Non-biological relationship to the recipient was associated with much lower loss of life years and risk of ESRD compared with those who were biologically related.
Conclusion
Asking donors whether they may be willing to give up between 0.5 and 1 year of life may be a better way to convey risk than giving them an estimate of their lifetime risk of ESRD.
In addition the study identifies the potential importance of following donors and treating risk factors aggressively to prevent ESRD and to improve donor survival
limitation of this study
The ability to predict lifetime outcomes from 15year follow-up in donors of all ages and medical conditions is a limitation.
Level of evidence (I am still confused either this is level 1 or 2
Nahla Allam
2 years ago
Summary:
Introduction:
30 000 live donor kidney transplant surgeries are performed ,Each year, the recipients’ benefits are improved life expectancy and quality of life comparedwith dialysis or deceased donor transplantation. The long-term risks are also p be undersized, especially in low-risk donors who are adequately screened.
Objectives
To estimate the potential loss of life and the added lifetime risk of ESRD in average-risk kidney donors.
Methods Model Description: The following are the critical assumptions for the model:
►► ESRD is increased in donors compared with non-donors.
►► ESRD in donors and non-donors will be associated with high mortality rates.
►► Donors and non-donors transition through a CKD state for at least one year before ESRD.
►► ESRD is increased in donors compared with non-donors. Therefore, we assumed there must have been an increase in the transition rate and CKD states.
►► Nephrectomy in donors will have a greater risk of falling below a GFR threshold of 60 mL/min/1.73 m2 than non-donors.
►► Cohorts are assumed to be non hypertension, diabetes mellitus, and proteinuria at donation. However, they are at risk of developing these conditions whether they donate, impacting patient survival and kidney function loss in both donors and non-donors. Given that some individuals may be at higher or lower risks of diabetes mellitus and proteinuria, smoke, or are obese, we examined these
in additional sensitivity analyses. Diabetes mellitus in non-donors would follow the same pattern (increasing rates with age) as in the general population, even though absolute rates might be lower (if initially screened to be negative).
►► CKD states will be associated with higher mortality rates than in the general population, but the magnitude of this effect was examined in additional sensitivity analyses.
►► Model transition rates from average to CKD states could be empirically derived (by working backward) to reproduce observed 15-year cumulative incidence rates for ESRD in donors and non-donors and can be used to project cumulative lifetime risks of ESRD subsequently. CKD in non-donors would follow the same pattern (increasing rates with age) as in the general population but at overall lower rates
The model was developed using TreeAge Pro 2015 (TreeAge Software, Williamstown, Massachusetts, USA). Ethics approval was not required because this is a theoretical model that uses published population data.
Patient involvement in study design:
The study design, development, and research question did not involve patient input, nor were outcomes informed by patient priorities
Target population
The base case cohorts were 40-year-old patients of both sexes and white/black race from the USA
Main outcome measures:
The health outcome of interest was remaining years of life (undiscounted). Since the quality of life is reduced in patients with ESRD and other related health states and these events are downstream, life years were scaled by quality measures and discounted at a 3% rate of time preference to calculate QALYs. Lifetime cumulative incidence
of ESRD was also calculated.
Intervention effects
Donors in the study underwent unilateral nephrectomy
Time horizon
The time horizon for remaining life years and QALYS was a lifetime
Analysis, design, and outcomes
All analyses compared outcomes of the same population of healthy potential donors and modeled the effects of all donated.
Non-donors were assumed to have 15-year cumulative ESRD risks of 0.067%, 0.045%, 0.21%, and 0.12% for white males, white females, black males, and black females, respectively. Donors were assumed to have 15-year cumulative ESRD risks of 0.34%, 0.15%, 0.96%, and 0.59% for white males, white females, black males, and black females, respectively.
Uncertainty and sensitivity analyses:
We assumed that many future risks that can impact life expectancy and ESRD, such as cancer, obesity, and smoking, were not influenced by the act of kidney donation
Results:
1- Overall, 0.532–0.884 remaining life years were lost from donating a kidney.
2-It was equivalent to 1.20%–2.34% of remaining life years (or 0.76%–1.51% remaining QALYs).
3-The risk was higher in male and black individuals.
The study showed that 1%–5% of average-age current live kidney donors might develop ESRD due to nephrectomy.
4- The added risk of ESRD resulted in a loss of only 0.126–0.344 remaining life years.
5-Most of the loss of life was predicted to be associated with chronic kidney
disease (CKD), not ESRD.
6-Most events occurred 25 or more years after donation. Reducing the risk of death associated with CKD had a modest overall effect on the percent loss of remaining life years (0.72%–1.9%) and QALYs (0.58%–1.33%).
7-Smoking and obesity reduced life expectancy and increased overall lifetime risks of ESRD in non-donors.
However, the percentage loss of remaining life years from a donation was not significantly different in those with or without these risk factors.
Conclusion:
Live kidney donation may reduce life expectancy by 0.5–1 year in most donors. The
development of ESRD in donors may not be the only measure of risk, as most of the predicted loss of life predates ESRD. The study identifies the potential importance of following donors and treating risk factors aggressively to prevent ESRD and improve donor survival.
Strength of study :
► The study projects the long-term risk of donating akidney, including loss of life and the added risk ofend-stage renal failure.
► These findings help quantify and communicate risk to potential donors and convey the importance of lifelong follow-up in actual donors.
► The study uses evidence of over 15 years of follow-up in actual live kidney donors and healthy controls.
Limitation :
► The ability to predict lifetime outcomes from 15- year follow-up in donors of all ages and medical conditions
Level 2
Heba Wagdy
2 years ago
Living donor kidney transplantation provides recipients with better quality of life and better life expectancy with mild risk to the donors and low postoperative mortality.
Long term risks are presumed to be low.
However, recently, studies suggested increased risk of ESRD and cardiovascular mortality after donation.
Kidney donors are at higher risk of CKD and proteinuria and may develop DM and HTN despite screening at time of donation leading to accelerated loss of kidney functions.
The impact of donation on remaining life years and remaining quality adjusted life years (QALY) is important to be considered with other behavioral and environmental exposures.
The study aimed to estimate the effect of donation on potential loss of life and increased lifetime risk of ESRD in average risk donors.
It depends on previously published analyses focused on risk of ESRD post donation without patient recruitment.
It showed that donation decrease potential life expectancy by 1-2%
Pre-dialysis mortality accounted for most of loss of life and decreased QALY so suggesting that progression from CKD to ESRD occur over years.
The association between donation and increased risk of death is not well determined as studies included have small numbers, lack healthy controls with short follow up duration.
Mortality risk in average age white donor is 0.2% lower than non donors
Modest decrease in percent of total life years and QALY after developing CKD.
White male donors have greater added long-term ESRD risks than expected, may be due to longer life expectancy or because white males may have more permissible criteria for donation.
The loss of life due to kidney donation is projected to be less than that due to smoking and obesity.
Younger donors have more added risks of ESRD and potential life years lost.
Smoking and DM lave large effect on overall survival and lifetime risk of ESRD in donors and nondonors.
The study suggest that weight loss and cessation of smoking are important for donors and nondonors.
Donor with non-biological relation have lower risks than related donors.
The study determined the potential importance of long-term follow up of donors, adequate treatment of risk factors and improving lifestyle to prevent ESRD and improve donor survival .
Limitations:
Compared rate of ESRD over 15 years in actual donors with theoretically matched cohort
Used historic mortality and disease incidence rate to make future projections.
It analyzed US donors with international population of non donors so can’t be generalized to donors from other countries with different ESRD rates.
Many variables and transition rates were included
Didn’t include multiple stages of CKD
Used cohort of 40 year old individuals for analysis, however donor have wide range of ages.
No data about family history of ESRD in nonbiological related donors.
Level 1 (Meta-analysis study)
Mohamed Mohamed
2 years ago
IV. Lifetime risks of kidney donation: a medical decision analysis Please summarise this article in your own words
This study aimed to estimate the long-term of death & ESRD in kidney donors.
Markov medical decision model was used to analyse ESRD in non-donors & donors.
The target population were 40-year-old patients of from the USA(male/female, white/black race); 40 year is the mean age of live donors & for whom recent estimates of 15-year risks of ESRD in non-donors & donors are available; the study relied on published analyses, not on recruiting participants.
The main outcome measured were:
– The potential remaining life years lost
– Quality-adjusted life years (QALYs)
– Added lifetime risk of ESRD from donation..
The intervention effect of the study is unilateral nephrectomy done in donors.
Secondary outcomes:
– The loss of life attributed to ESRD. Results
-The remaining life years lost from donation: 0.532 (white female) to 0.884 years (black female). This was equivalent to 1.20%–2.34% of remaining life years (or 0.76%–1.51% remaining QALYs). The risk was higher in male & black donors.
-The added lifetime cumulative risk of ESRD: 1.135% (white female) to 4.645% (black male); this means 1 added ESRD event for every 88 white female or 1 added ESRD event for every 22 black male donors.
-The % loss of life due to ESRD in relation to total remaining years of life: 0.29% (white female) to 0.88% (black male). Most of the loss of life was associated with CKD not ESRD. Most events occurred 25 or more years after donation.
-Smoking & obesity reduced life expectancy & increased lifetime risks of ESRD in non-donors; however the % loss of remaining life years from donation didn’t differ in those with or without these risk factors. Discussion
Donation potentially shortens life in average-age donors by about 1%–2%.
Short-term studies (<20 years) might not detect adverse effect on survival.
ESRD is associated with very high mortality rates; however a significant % of the loss of life was associated with CKD not ESRD.
Risk factors associated with higher rates of death & ESRD (smoking, obesity & biological relationship) were also explored.
From studies with small number of patients it was unclear whether there is a significant risk of death from donation; an important mortality signal could have easily been missed.
In this study, the % of patients modeled to be alive at 20 years post nephrectomy for an average-age white male donor was only 0.2% lower than a non-donor. Greater differences were seen later (more than 30 years) when the cumulative effects of CKD were more evident. The lower GFR CKD from donating a kidney may well be different from the CKD due to proteinuria or DM; however, risks associated with CKD explored in the model showed only a modest reduction in the % of total life years & QALYs lost.
The model included probability that some donors will develop DM, HTN & proteinuria at a later date; these would have impact on health (overall survival & progression to ESRD) as they do in the general population.
The white males have greater added long-term ESRD risks from donation than would be anticipated.
The loss of life from live kidney donation is far less than smoking or mild obesity.
Smoking & DM diabetes mellitus had large effects on overall survival & in lifetime risks of ESRD in donors and non-donors; the effects were less with obese donors compared with smoking or DM.
A 40-year-old white female with DM (otherwise well) , has the same added risk of ESRD & % loss of life years as a current ideal 40-year-old black male donor. Limitations
Historic mortality & disease incidence rates were used to make accurate future lifetime projections.
US donors were included (the non-donor controls were both US and international); so, the results may not be applicable to live kidney donors from other countries where population ESRD rates are much lower. ================================ What is the level of evidence provided by this article? Level II
Abdulrahman Ishag
2 years ago
The aim o the study ;
This study estimated the potential loss of life and the lifetime cumulative risk of end-stage renal disease (ESRD) from live kidney donation.
Methods;
A USA-based Markov model was used to examine the risk of ESRD in a population of non-donors and donors.
Patient involvement in study design;
There was no patient recruitment or participation in this study but rather the study relied on prior published analyses.
Target population;
The base case cohorts were 40-year-old patients of both sexes and white/black race from the USA. This is the mean age of live donors (median age 38) and for whom there are recent published estimates of 15-year cumulative risks of ESRD in non-donors and donors.
Main outcome measures;
Potential remaining life years lost, quality-adjusted life years (QALYs) lost and added lifetime cumulative risk of ESRD from donation.
Intervention effects;
Donors in the study underwent unilateral nephrectomy. It is assumed that the nephrectomy results in a loss of GFR, and this loss of function would increase the probability of transitioning from a normal (GFR ≥60 mL/min/1.73 m2) kidney function heath state to CKD.
Analysis and design
1-All analyses compared outcomes of the same population of healthy potential donors and modelled the effects if all donated.
2- In addition we examined the loss of life attributed to ESRD by eliminating the ESRD health state in both donors and non-donors and assumed all remained in CKD until death.
3-In the base case analysis, age, sex and black/white race annual transition rates for proteinuria, diabetes mellitus and hypertension were empirically derived from population studies assuming that donors were initially disease-free but could subsequently develop these conditions at rates seen in the general population.
The results ;
1-Live kidney donation may reduce life expectancy by 0.5–1 year in most donors.
2-The development of ESRD in donors may not be the only measure of risk as most of the predicted loss of life predates ESRD.
3-The study identifies the potential importance of following donors and treating risk factors aggressively to prevent ESRD and to improve donor survival .
Conclusion;
1-The analysis shows that younger donors have greater added risks of ESRD and potential life years lost; however, the percentage loss of life was somewhat less compared with older cohorts.
2-The effect of smoking and diabetes mellitus had large effects on overall survival and in lifetime risks of ESRD in donors and non-donors. The effects were less in obese donors compared with donors who were smoking or had diabetes mellitus.
3-The incremental effects with donation in subjects with and without obesity and smoking varied slightly by sex and race but overall were not very different .
4-The analysis suggests that counseling and interventions to reduce weight and smoking cessation are more important to both donor and non-donor and less of an argument to deny donation.
5- Having a non-biological relationship to the recipient was associated with lower risks; however, the majority of donors are related.
6- Donors with diabetes mellitus were at very high added risks of ESRD and death. It is interesting to point out that a 40-year-old white female with diabetes mellitus, who is otherwise well, has about the same added risk of ESRD and percentage loss of life years as a current ideal 40-year-old black male donor.
What is the level of evidence provided by this article?
Level III
Retrospective cohort study .
Isaac Abiola
2 years ago
SUMMARY:
The growth in the number of successful kidney transplantation has brought a remarkable improvement in the quality of life of the recipient but the same cannot be said of the donor. Furthermore, some studies has shown an increase in cardiovascular disease, CKD, and ESRD among donor with long term follow up.
The objective of the study:
to estimate the potential loss of life and the added lifetime risk of ESRD in average donor.
Methods:
The US based Markov model was used to evaluate the risk of ESRD in participant non donor and kidney donor
cohort are assumed to be free of hypertension, DM and proteinuria at the time of donation
the median age of cohort is 38 years comprising of both sexes, black and whites
donors in the study underwent unilateral nephrectomy which is assumed to result in loss of GFR
non-donors were assumed to have 15- year cumulative risk of ESRD of 0.067%, 0.045%, 0.21%, and 0.12% for white male, female, black male and black female respectively
donor were assumed to have 15- year cumulative ESRD risk of 0.34%, 0.15%, 0.96%, 0.59% for white male, female, black male, and female respectively
in the sensitivity analysis, the cumulative 15-year risk of ESRD in non donor were found to be higher than the published
Results:
life donation was associated with an increase risk of ESRD especially among the male and black race
the added lifetime cumulative risk of ESRD varied from 1.135% among the white female to 4.645% in black male
50% of all ESRD occurrence was seen after 25 years
in the sensitivity analysis, the added cumulative of developing ESRD were projected to be lower in the idea cohort compared to case analysis
non biological relationship with the recipient was associated with lesser loss of year and risk of ESRD compared to biologically related
in other sub-group analysis, younger patients lost more potential life and risk of ESRD due to longer years of exposure to reduce kidney function, though on percentage level older patient lost more years
obese patient, smoker, and DM are more at risk, but DM patient suffer the most hit to loss of years and increase risk to ESRD
Conclusion
The study showed that kidney donation do shorten life by 1%- 2%, though short term study (<20 years) with appropriate control may not show any adverse outcome on survival. It is of note that, the overall loss of life in the entire population is average, but the impact on the younger donor are more compared to those that donate kidney at old age,
The level of evidence is 2
Hussein Bagha baghahussein@yahoo.com
2 years ago
This study was based on risk prediction model to assess the lifetime risks of kidney donation. The authors used the Markov medical decision model to come up with the incidence of :
A USA-based Markov model was used to examine the risk of ESRD in both donors and non-donors.
The authors used a previously published model and updated it to include the population under study and ESRD vital statistics and current cumulative risks of DM, CKD and ESRD from published sources. So, there was no actual patient involvement or recruitment for this study. The study relied on previously published data.
The case cohorts chosen were 40 year old male and female Caucasian and African-American subjects. The primary outcomes were remaining years of life, QALYs lost and the cumulative incidence of developing ESRD. The study looked at intervention effects in the donors. The intervention in donors was a unilateral nephrectomy and the effects was what was looked at which was the loss of GFR and progression to CKD – GFR < 60 mls/min. The patients were followed for life apart from the outcome for ESRD which was stopped at 90 years. The cohort was healthy potential donors and they were analyzed for outcomes assuming they had all donated. Transition rates from normal GFR to CKD were derived from previously published studies. The rates were multiple by an empirically derived coefficient that was lower in the non-donors than the donors to reproduce the 15 year ESRD risking non-donors and donors. The age, gender and race annual transition to develop proteinuria, DM and HTN were also derived from previously published studies.
The projected survival was similar between donors and donors up to 20 years after which it was higher in the non-donors. The remaining life-years lost after donation was highest in African American males and lowest in the Caucasian females. The percent loss of QALYs was also highest in African American males and lowest in Caucasian females.The lifetime cumulative risk of ESRD was 1.135% in Caucasian females and 4.645% in African males. The precent loss of life attributed to ESRD in relation to total remain years of life varied between 0.29% for White females and 0.88% for African males.
In the sub-analysis, the younger population of patients had more life years lost and had a higher risk of developing ESKD – because they would live longer with a unilateral kidney. Donors with DM suffered the the greatest loss of life years and had the highest risk of developing ESRD.
If the donors were not biologically related to the recipient, they would have a lower incidence of lost life years and progression to ESRD.
A very important point of this study is that for up to 20 years there may be no difference between donor and non-donors. The differences become apparent after 20 years. Future studies need longer follow up periods of more than 20 years. A significant proportion of mortality was due to CKD and not ESRD as was expected. The presence of CKD also accounted for most of the reduction in QALYs. Therefore, it is important to identify risk factors that will lower GFR to develop CKD like DM, HTN, proteinuria and treat them appropriately. The risk of developing ESRD increased in the White males after 25030 years of follow up possibly due to longer life expectancy of the white males.
The study had several limitations:
It used data from real kidney donors to project the rate of ESRD over 15 years in non-donors
The donors were all from the US whereas the non-donor population was from US as well as other countries. Therefore, the results cannot be generalized to donors from other countries.
The model did not include the stages of CKD
Level of evidence
The level of evidence is level II. This is a case cohort study followed up for 15 years. The outcomes were identified and analyzed for the risk factors based on previously published data
Mohammad Alshaikh
2 years ago
Please summarise this article in your own words
Study objective : estimation of potential loss of life and the lifetime cumulative risk of ESRD in living donors in US in comparison to international cohort.
Target population : 40 year-old ( the mean age of kidney donors) of both sexes with different races in the USA , compared to an international donors cohort from different ages and races. measuring an estimate on 15-year cumulative risk of ESRD in non donors and donors, knowing the overall effect of donation in remaining life years and quality adjusted life years (QALYs)
Results:
The differences between donors and non donors appear in 20 years post donation, life years lost from donation and QALYs were more pronounced in black males.
more than 50% of all ESRD events occurs 25 years or more after donation.and was more in black males.
Donors spent 50-85 %more time with an isolated low GFR.
Younger lost more potential years of life and greater risk of ESRD, but loss of life was greater in older donors.
The study explore risk factors associated with increased risk of death an ESRD, ie; obesity, smoking, biological relationship, hypertension and DM, so intervention could help in preventing ESRD and improve survival.
Donation shortens life in average age-age donors by 1-2%.
Limitations:
Analyse US donors compared ti international non-donors.
Not includes all stages of CKD and proteinurea levels.
Only 40 year old donors were compared to all ages in the cohort.
Conclusion:
All donors should be evaluated and followed after donotaion and the risk factors identified and treated ( obesity , smoking , HTN, etc ), as these modifiable risk factors could decrease the risk of ESRD development.
The donation decrease life expectancy by 0,5 – 1 year.
What is the level of evidence provided by this article? Level of evidence is IIc – outcome research (cohort)
Ajay Kumar Sharma
Admin
2 years ago
My reply is related to the level of evidence this article provides. Your answers have varied from level 2 to level 3. It is a simplified approach when it is not an RCT: Stepwise approach: Q 1: Is it an observational study or an interventional study. A 1: It is an observational study. Donor nephrectomy is an operation been performed in study group but it is not an intervention from the point of view of research. Q2: Is it a longitudinal study or a cross sectional study? A 2: It is a longitudinal study. Q3: We know that it is a longitudinal study. Is it a cohort study or case control study? A 3: Case-control studies are always retrospective, we find out the end-point (ESRD, death, DM or HT in donors) and one looks back for underlying factors. While in cohort studies ( that is either prospective or retrospective) we start with risk factors and follow these patients to look for the end-point (primary, co-primary and secondary). Conclusion: This is an observational longitudinal cohort study with population data as controls.
Therefore, this article provides level 2 evidence.
Last edited 2 years ago by Ajay Kumar Sharma
Ajay Kumar Sharma
Admin
2 years ago
Apologies, this was deleted as it was repetition of my reply.
Last edited 2 years ago by Ajay Kumar Sharma
Mohamad Habli
2 years ago
The provided article s a metanalysis with level of evidence 1
The study evaluated the potential remaining life years lost, quality-adjusted life years lost and added lifetime cumulative risk of ESRD from donation.
A USA-based Markov model was used to examine the risk of ESRD in a population of non-donors and donors. The base case cohorts were 40-year-old patients of both sexes and white/black race from the USA. This is the mean age of live donors (median age 38) and for whom there are recent published estimates of 15-year cumulative risks of ESRD in non-donors and donors
The study design, development and research question did not involve patient input, nor were outcomes informed by patient priorities. There was no patient recruitment or participation in this study but rather the study relied on prior published analyses.
Results
– The projected survival of average-age donors and non-donors appears to show differences in survival between the cohorts after 20 years or more after donation.
– Life years lost from donation is 0.532 years for white female and 0.884 years for black female donors.
– Loss of life percent is 1.20% for white female and 2.34% for black male.
– The per cent loss of total QALYs is 0.76% for white female and 1.51% for black male.
– The added lifetime cumulative risk of ESRD varied from 1.135% in white female to 4.645% in black male
– The added ESRD events tended to occur earlier in black male compared with white male.
– In a subgroup analyses younger patients lost more potential years of life and had potentially greater risks of ESRD given longer exposure to reduced kidney function.
– Non-biological relationship to the recipient was associated with much lower loss of life years and risk of ESRD compared with those who were biologically related.
KAMAL ELGORASHI
2 years ago
The study estimates potential loss of life, and lifetime cumulative risk of ESKD, as a result of live kidney donation. Methods.
A USA -based Markov models was used to examine the risk of ESKD in donors and non-donors in general population . Key assumptions of the models:
ESKD in both donors and non-donors generaly associated wiyh high risk of mortality rate .
Donors and non-donors transition through CKD state for at least 1 year before developing ESKD .
Since ESKD rate increasing in donors compared with non-donors, we assume that; there have been an increase in the rate of transition to and time spent in CKD state.
Nephrectomy in donors will quantitatively reduce overall risk of kidney failure, decline rate increased in donors with time.
Cohorts are assumed to be free of HTN, DM, proteinuria, at donation, however; there are risks of developing complications whether in donors or non-donors.
CKD state associated with increased mortality as in general population.
Model transition rate from normal to CKD, could be derived to reproduce observed 15 years cumulative incidence rate for ESKD, and can be used to subsequently project lifetime cumulative risk of ESKD.
Previous published study was updated to include current general population and ESKD vital statistics, and cumulative risk for DM, CKD, ESKD.
Target population;
Base case cohort were 40 years old, from both sexes, white and black, from USA.
The primary outcome noted that , the net difference in remaining life years, QALYs, and development of ESKD . Results;
Differences in survival between cohort becomes apparent after 20 years post donation, remaining life years lost from donation ranged from 0.532 years for white female, and 0.883 years for black female donors.
Percent of life loss was highest in black male donors.
Percent loss of life varied from 1.20 % for white female to 2.34% for black male.
Percent loss of total QALYs varied from o.76% from white female, to 1,51% for black male.
Living kidney donors was associated with an added risk of ESKD, especially among those of male sex for black male, the lifetime cumulative rsik of ESKD varied from 1.135% in white female to 4.4645% in black male, this translated to one added ESKD event for every 88 white female or one added ESKD event for every 22 black male donors.
> 50% of all ESKD events in donors occurred at 25 years or more post donation.
The added ESKD risk events tends to occur earlier in black male compared to white male .
percent loss of life to ESKD varied between 0.29% for white female and 0.88 % for black male.
Younger patients lost more potential years of life and potentially have greater risk of ESKD given longer exposure to reduce kidney function.
Loss of life was greater in older compared with younger donors.
Life expectancy markedly reduced and lifetime risk of ESKD increased for cohort whio were smoker or diabetics or obese.
DM donors greatest loss of life years and increase risk of ESKD.
Non-biological relationship to recipients associated with lower loss of lifetime risk of ESKD, compared with biologically related. Discussion;
Awareness by long-term risks associated with kidney donation, is vital to potential donors, this analysis show that short term studies (<20 years), even with appropriate normal control are not likely to detect adverse effect on survival.
Although ESKD is associated with very high mortality rate , a significant percent of loss of life was associated with CKD not ESKD.
Study also explore risk factors associated with higher rate of death and ESKD, such as smoking, obesity , and bilogical relationship to the recipients.
Lower GFR as a result of donation , well different from CKD that associated with proteinuria, DM, , and the lower mortality rate associated CKD as a result of donation from CKD from general population.
The lost rate of life per time post donation , increases may be because of some donors develop DM ,HTN, proteinuria post donation.
The objectives; to estimate the potential loss of life as well as the added lifetime risk of ESRD in average-risk kidney donors. Design; A USA-based Markov model was used to examine the risk of ESRD in a population of non-donors and donors.
The study relied on prior published analyses. Target population; 40-year-old patients of both sexes and white/black race from the USA. Intervention Live donor nephrectomy. Main outcome and measures Potential remaining life years lost, quality-adjusted life years (QALYs) lost and added lifetime cumulative risk of ESRD from donation. Time horizon The time horizon for remaining life years and QALYS waslifetime. However, for ESRD, the cumulative incidencewas truncated at age 90 in keeping with other studies Analysis; All analyses compared outcomes of the same population of healthy potential donors and modelled the effects if all donated.
Cohort assumed that donors were initially disease-free but could subsequently develop these conditions at rates seen in the general population. Results:
Differences in survivalbetween the cohorts became apparent after 20 years ormore after donation.
The remaining life years lost from donation ranged between 0.532–0.884
This was equivalent to 1.20%–2.34% of remaining life years (or 0.76%–1.51% remaining QALYs).
The risk was higher in male and black individuals.
The study showed that 1%–5% of average-age current live kidney donors might develop ESRD as a result of nephrectomy.
The added risk of ESRD resulted in a loss of only 0.126–0.344 remaining life years.
Most of the loss of life was predicted to be associated with chronic kidney disease (CKD) not ESRD.
Most events occurred 25 or more years after donation.
Death during the CKD health state accounted for most of the projected increase in mortality and reduction in QALYs. Intuitively this makes some sense given that the transition from CKD to ESRD can be over many years and that progressive kidney disease is associated with graded increases in mortality
Despite differences in the absolute rates of ESRD in both donors and non-donors, the absolute and percent loss of life years and QALYs from donation were only modestly lower compared with the base case analysis.
Smoking and obesity reduced life expectancy and increased overall lifetime risks of ESRD in non-donors.
However the percentage loss of remaining life years from donation was not very different in those with or without these risk factors.
Conclusion Live kidney donation may reduce life expectancy by 0.5–1 year in most donors. The development of ESRD in donors may not be the only measure of risk as most of the predicted loss of life predates ESRD. The study identifies the potential importance of following donors and treating risk factors aggressively to prevent ESRD and to improve donor survival.
What is the level of evidence provided by this article?
the study based on published analysis, systemic review level 1
Doaa Elwasly
2 years ago
-Introduction
Mostly the risk for donors is small particularly if they are of low risk and are followed regularly.
Recent studies highlighted that kidney donors are at high risk of development of CKD ,ESRD and cardiovascular complications others can develop HTN ,DM on long term bases.
A study assessed the 15 years and life time risk of experiencing ESRD in potential non donors and revealed that candidates with minor medical comorbidities , male , and those of black race are subjected to higher risk.
This study aims at evaluating the possible death and the added lifetime risk of ESRD in average-risk kidney donors. Methodology
Markov model was used to evaluate the risk of ESRD in non-donors and donors.
This model supposed that;
· ESRD will be more associated with donors than non donors and that both candidates with ESRD will have high mortality rate.
· Both candidates will go through CKD before reaching ESRD
· Nephrectomy will be associated with low GFR threshold of 60mL/min/1.73m2 compared with non-donors.
· Candidates are supposed to be disease free and can be at high risk of developing DM ,HTN , or proteinuria later on if donated or if didnot donate along with their impact on survival and renal function
· CKD cases have high mortality risks
· Transition rates from normal to CKD states
Can be derived to reproduce observed 15-year cumulative incidence rates for ESRD in donors and non-donors .
The study included data published before on the estimates of 15-year cumulative risks of ESRD in non-donors and donors for 40 y old candidates of both sexes and races.
QALYs were calculated and lifetime cumulative incidence of ESRD was also calculated. Results
Survival variation between the cohorts was noticed after 20 years or more after donation.
The per cent loss of life was highest in black male donors.
The % loss of life ranged from 1.20% for white
female to 2.34% for black male. The % loss of total
QALYs varied from 0.76% for white female to 1.51% for black male.
The added lifetime cumulative risk of ESRD
Ranged from 1.135% in white female to 4.645% in black male.
Most ESRD events in donors happened 25 years or more
after donation.
Donors experienced 50%–85%more time with an isolated low GFR CKD compared with non-donors.
Overall % loss of remaining life years of 1.39%, 0.72%, 1.9% and 1.74% for white male, white female, black male and black female, respectively.
Younger candidates were subjected to more loss of years of life and higher liability of ESRD development due to longer time of exposure to low GFR , on the other hand on % bases loss of life was greater in older candidates.
ESRD and less life expectancy were associated with smoking, obesity and DM mean while obese smoker donors had little less risk than non obese non smoker donors.
Diabetic donors had the greatest loss of life years and increased risk of ESRD.
Life loss and ESRD were higher in biologically related donors to recipients. Discussion
This study revealed that donation can shorten life in average age donors by 1%–2% also short-term studies even with suitable controls are unable to detect an adverse effect on survival. CKD not ESRD was associated with significant % of life loss.
Risk factors associated with increased risk of ESRD and death as smoking, obesity and DM were assessed.
Meanwhile it is not clear whether donation has a significant impact on death risk or not.
The possible % to be alive after 20 y of donation for average aged white donor is 0.2% less than matched non donor candidate.
CKD occurring due to low GFR post donation need to be differentiated from CKD associated with proteinuria and DM .
Some studies noticed that DM and HTN can occur post donation and lead to ESRD.
The model overestimated the lifetime ESRD predictions in non-donors .
White males had long-term ESRD higher risks from donation than would be supposed could be due to longer life expectancy .
Death due to donation is much less than death due to smoking or obesity
Live partial liver donation seems to be less risky over time than live renal donation although the former has higher perioperative mortality risk .
Smoking and diabetes mellitus had great impact on overall survival and in lifetime risks of ESRD
in donors and non-donors. The effects were less in obese donors compared with donors who were smoking or had diabetes mellitus.
Smoking cessation and wight loss are important to donors and non donors and less debatable topic for forbidding donation.
A 40-year-old white female with diabetes mellitus, who is otherwise well, has the same added risk of ESRD and percentage loss of life years as a current ideal 40-year-old black male donor.
Old mortality and disease incidence rates were used to make future lifetime projections is a significant
Limitation as ESRD and DM risk are increasing.
There were many variables and transitions included in the model but CKD stages were not included.
The ability to predict lifetime prognosis from 15-
year follow-up of donors of all ages and medical
conditions is a limitation.
Informing the donors about the possibility of giving up between 0.5 and 1year of life may be a better way to explain the risk than giving them an
estimate of their lifetime risk of ESRD
Long term follow up of donors is essential to avoid risks .
-level of evidence is III
Assafi Mohammed
2 years ago
Lifetime risks of kidney donation: a medical decision analysis
Summary of the Article
CKD is associated with multiple comorbidities and the noticed increased in mortality related to CKD is an important driver of life years lost.
In this study, a USA-based Markov model was used to examine the risk of ESRD in a population of non-donors and donors. There was no patient recruitment or participation in this study but rather the study relied on prior published analyses.
In this study, a sensitivity analysis was assumed that the added time spent in isolated CKD (no proteinuria nor diabetes mellitus) in donors compared with non-donors was not associated with an increase in mortality. In other sensitivity analyses age at donation, smoking status, higher body mass index, new-onset diabetes mellitus and biological relationship to recipient were explored.
The targeted population were 40-year-old patients of both sexes and white/black race from the USA.The time horizon for remaining life years and quality-adjusted life years (QALYS) was lifetime.
Study outcome
1. Differences in survival between the cohorts became apparent after 20 years or more after donation.
2. More than 50% of all ESRD events in donors occurred 25 years or more after donation.
3. The added lifetime cumulative risk of ESRD varied from 1.135% in white female to 4.645% in black male.
4. The per cent loss of life attributed to ESRD in relation to total remaining years of life varied between 0.29% for white female and 0.88% for black male.
5. On a percentage basis, loss of life was greater in older compared with younger donors.life was greater in older compared with younger donors.
6. Life expectancies were markedly reduced and lifetime risks of ESRD increased for cohorts who were smokers or had diabetes mellitus.
7. Surprisingly the absolute loss of life years was slightly less in donors who were obese or smoked compared with donors without these conditions.
8. Donors with diabetes mellitus suffered the greatest loss of life years and increased risk of ESRD.
9. The effect of smoking and diabetes mellitus had large effects on overall survival and in lifetime risks of ESRD in donors and non-donors.
10.Live kidney donation is found to be associated with less peri-operative death rate(0.31death/1000 operations in comparison to live liver donation(1.7/1000), but kidney donation results in more loss of life when adding in the long-term impact.
11.The non-biological relationship to the recipient was associated with lower risk.
Limitations of the study
1. Life expectancy and the cumulative incidences of diabetes mellitus and ESRD are increasing.
2. Using historic mortality and disease incidence rates to make accurate future lifetime projections is a significant limitation.
3. The study was an analysis of US donors, whereas the non-donor control population included US and international populations. The results may not be generalized to live kidney donors from other countries where population ESRD rates are much lower.
4. The model did not include multiple stages of CKD.
5. There was no data on family history of ESRD in the non-biological-related donors.
6. There are many variables and transition rates included in this model and addressing uncertainty in each.
7. Combinations of variables would require a much longer paper.
8. The key uncertainties explored were the cumulative risks of developing ESRD and the increased mortality associated with CKD states..
Strength of the study
1. Asking donors whether they may be willing to give up between 0.5 and 1year of life may be a better way to convey risk than giving them an estimate of their lifetime risk of ESRD.
2. The study identifies the potential importance of following donors and treating risk factors aggressively to prevent ESRD and to improve donor survival.
What is the level of evidence provided by this article?
This is a retrospective study .
Level of evidence is grade III.
Weam Elnazer
2 years ago
Objective:
According to the findings of this research, live kidney donation may increase both the risk of death and the cumulative risk of developing the end-stage renal disease (ESRD) over a lifetime.
Design: a Markov model for clinical decision making.
Participants were 40-year-old live kidney donors of either black or white race who were of either gender.
Intervention Nephrectomy performed on a live donor.
The main outcome and evaluating criteria are Loss of potential remaining life years, quality-adjusted life years (QALYs), and an increase in the lifetime cumulative risk of end-stage renal disease (ESRD) due to donation.
Results:
Overall, kidney donation resulted in a loss of between 0.532 and 0.884 more years of life. This was comparable to 0.76%–1.51% of the remaining quality-adjusted life years (or 1.20%–2.34% of the remaining life years). Males and those of African descent have a significantly increased risk. According to the findings of the research, the incidence of end-stage renal disease (ESRD) after nephrectomy ranges from 1% to 5% among current living kidney donors of average age. The increased likelihood of developing ESRD was associated with a reduction of just 0.126–0.344 more life years lost. It was anticipated that most deaths would be caused by chronic kidney disease (CKD), and not the end-stage renal disease (ESRD). The majority of activities took place at least 25 years following the contribution. The reduction of the increased risk of mortality associated with CKD had a small overall impact on the percentage of remaining life years (0.72–1.9%) and QALYs (0.58–1.33%) that were lost. In non-donors, the effects of smoking and obesity were a decrease in life expectancy and an increase in the total lifetime risk of ESRD. However, there was not a significant difference in the proportion of remaining life years lost due to donation between individuals who had these risk factors and those who did not.
Conclusion In most people, donating a kidney while they are still alive may cut their life expectancy by half a year to one year. It is possible that the development of ESRD in donors is not the sole measure of risk, given that the majority of the anticipated loss of life occurs prior to the formation of ESRD. The research highlights the potential significance of monitoring donors and addressing risk factors in a proactive manner in order to reduce the incidence of end-stage renal disease (ESRD) and increase donor survival.
What is the level of evidence provided by this article?
-This study estimated the potential loss of life and the lifetime cumulative risk of (ESRD) from live kidney donation.
-Nearly 30 000 live donor kidney transplant surgeries are performed throughout the world each year.
-The risks to the donors are generally felt to be small to modest, with a low postoperative mortality (approximately 3.1 deaths per 10 000 operations).
-The long-term risks are also presumed to be small especially in low-risk donors who are adequately screened.
-Recent reports however show that there is some increase in risk of (ESRD) from donation and possibly an increase in cardiovascular
mortality.
-Patients who donate a kidney may be at greater risk of developing (CKD) as defined by a low (GFR) of <60 mL/ min/1.73 m2 or proteinuria and some donors will develop diabetes mellitus and may be at higher risk of developing hypertension.
-This study were to estimate the potential loss of life as well as the added lifetime risk of ESRD in aver- age-risk kidney donors. Methods
-The risk of ESRD in a population of non-donors and donors.
-The transition from the normal health state through other health states. The following are the key assumptions for the model:
– ESRD rates are increased in donors compared with non-donors.
– ESRD in both donors and non-donors will be associateed with high mortality rates.
– Donor and non-donors transition through a CKD state for at least 1 year before developing ESRD.
-ESRD rates are increased in donors compared with non-donors, we assumed there must have been an increase in the rate of transition to and time spent in CKD states.
-Nephrectomy in donors will quantitatively reduce overall patient kidney function.
– Given that kidney function declines over time in most individuals, donors will have a greater risk of falling below a GFR threshold of 60 mL/min/1.73 m2 compared with non-donors.
-Cohorts are assumed to be free of hypertension, diabetes mellitus and proteinuria at donation, and risk of developing these conditions whether they donate or not, and these will impact patient survival and loss of kidney function in both donors and non-donors.
-Given that some individuals may be at higher or lower risks of diabetes mellitus and proteinuria, smoke or are obese, we examined these in additional sensitivity analyses.
-Diabetes mellitus in non-donors would follow the same pattern (increasing rates with age) as in the general population even though absolute rates might be lower (if initially screened to be negative).
– CKD states will be associated with higher mortality rates as in the general population, but the magnitude of this effect was examined in additional sensitivity analyses.
– Model transition rates from normal to CKD states could be empirically derived (by working backwards) to reproduce observed 15-year cumulative incidence rates for ESRD in donors and non-donors and can be used to subsequently project lifetime cumulative risks of ESRD.
-CKD in non-donors would follow the samepattern (increasing rates with age) as in the general population but at overall lower rates.
Target population
-The base case cohorts were 40-year-old patients of both sexes and white/black race from the USA.
-This is the mean age of live donors (median age 38) and for whom
there are recent published estimates of 15-year cumulative risks of ESRD in non-donors and donors. Main outcome measures
-The health outcome of interest was remaining years of
life (undiscounted).
-Since quality of life is reduced in patients with ESRD and other related health states, and that these events are downstream, life years were scaled by
measures of quality and discounted at a 3% rate of time preference to calculate QALYs.
-Lifetime cumulative incidence of ESRD was also calculated.
Uncertainty and sensitivity analyses
-The lifetime estimates of ESRD were found to be higher in non-donors than published estimates, in part since this model incorporated the possibility that some participants could develop diabetes mellitus and proteinuria.
– Ideal non-donors were assigned lower incidence rates of diabetes mellitus, proteinuria and rates of transition to CKD to match projected lifetime ESRD risks rather than calibrating to 15-year ESRD risks.
-Non-donors were assumed to have lifetime cumulative ESRD risks of 0.43% (95% CI 0.19 to 0.58), 0.29% (95% CI 0.13 to 0.47), 1.00% (95% CI, 0.49 to 1.37) and 0.85% (95% CI, 0.37 to 1.35) for white male, white female, black male and black female, respectively.
-The increase in mortality associated withCKD is an important driver of life years lost, in a sensitivity analysis we assumed that the added time spent in isolated CKD (no proteinuria nor diabetes mellitus) in donors compared with non-donors was not associated with an increase in mortality.
Results
This was equivalent to 1.20%–2.34% of remaining life years .
-The risk was higher in male and black individuals.
-The study showed that 1%–5% of average-age current live kidney donors might develop ESRD as a result of nephrectomy.
-The added risk of ESRD resulted in a loss of only 0.126–0.344 remaining life years.
-Most of the loss of life was predicted to be associated with (CKD) not ESRD.
-Most events occurred 25 or more years after donation.
– Reducing the increased risk of death associated with CKD had a modest overall effect on the per cent loss of remaining life years (0.72%–1.9%) and QALYs (0.58%–1.33%).
– Smoking and obesity reduced life expectancy and increased overall lifetime risks of ESRD in non-donors.
– However the percentage loss of remaining life years from donation was not very different in those with or without these risk factors.
strengths and limitations of this study
– The study projects the long-term risk of donating a
kidney, including loss of life and the added risk of ESRD.
– These findings help quantify and communicate risk to potential donors and convey the importance of lifelong follow-up in actual donors.
– The study uses evidence of over 15 years of follow up in actual live kidney donors and healthy controls.
– The ability to predict lifetime outcomes from 15 year follow-up in donors of all ages and medical conditions is a limitation.
Conclusion
– Live kidney donation may reduce life expectancy by 0.5–1 year in most donors.
–The development of ESRD in donors may not be the only measure of risk as most of the predicted loss of life predates ESRD.
-The study identifies the potential importance of following donors and treating risk factors aggressively to prevent ESRD and to improve donor survival.
What is the level of evidence provided by this article?
The level of evidence 2
Kidney donation improves quality of life of recipient but may be associated with some risks. There can be perioperative morbidity and risk of death ( 3.1 @10000 donations). There can also be increased risk of Cardiovascular problems and ESRD.
The objective of this study was to assess the potential loss of life and risk of ESRD post kidney donation.
The study used Marko Medical decision analysis . 40 patients of both sex underwent donor Nephrectomy.
Results
The study found that there can be some loss of life years between 0.5-0.9 years ( 0.7-1.7 QALY).
The risk was higher in male and Blacks.
The risk of loss of life was associated with CKD and not ESRD.
Majority events happened 25 years post donation.
Smoking and obesity was found to be associated with decreased life expectancy and increased risk of ESRD.
Conclusion
Living kidney donation can decrease life expectancy by 0.5-1 years.
There is risk of ESRD post donation.
It is important to follow donors and treat risk factors to prevent ESRD to improve donor longevity.
What is the level of evidence provided by this article?
Living donation is associated with an increased incidence of the following.
A. Hypertension
B. Proteinuria
C. CKD
D. DM
E. Preeclampsia
Please justify your answer by giving the incidence of the event if it is a real risk. THERE IS NO ANNOUNCEMENT FOR THIS CHALLENGE. The reward will be restricted to the successful contributors ONLY.
A. This may be true in high risk indiviuals e.g. African American, Hispanic, high BMI and older donor= 50% increased relative risk (Lentin KL et.al. & Muller TF et al. 2012)
B. This is true as well but the amount of proteinuria is usually small. In meta-analysis,the donrs had protein excretion of 83 mg/ day versus 147 mg/day in the contol group, 95% CI 24-108
C. This true in one study, the hazards ratio for ESRD was 11.38. In another study it was
31/1000
D. Correct, donating to family member with type1 DM increase the risk , HR is 2.97 (Ibrahim et al.), BMI > 30 HR 2.97, AGE > 45 HR 1.46
E. Correct statment, preeclampsia was in 11% of donors compared to the non-donors control 5% ( Amit X, Garg et.al)
Thank you, Ben, for trying. Type 1 DM should not be a donor in the first place.
A- Hypertension : Correct
B- Proteinuria : Correct
C- CKD : Correct
D. DM : False
E. Preeclampsia : Correct
REFERANCES
1- Sanchez OA, Ferrara LK, Rein S, et al. Hypertension after kidney donation: Incidence, predictors, and correlates. Am J Transplant 2018; 18:2534.
2- Boudville N, Prasad GV, Knoll G, et al. Meta-analysis: risk for hypertension in living kidney donors. Ann Intern Med 2006; 145:185.
3- Garg AX, Prasad GV, Thiessen-Philbrook HR, et al. Cardiovascular disease and
hypertension risk in living kidney donors: an analysis of health administrative data in Ontario, Canada. Transplantation 2008; 86:399.
4- Kasiske BL, Anderson-Haag T, Israni AK, et al. A prospective controlled study of living kidney donors: three-year follow-up. Am J Kidney Dis 2015; 66:114.
5- Doshi MD, Goggins MO, Li L, Garg AX. Medical outcomes in African American live kidney donors: a matched cohort study. Am J Transplant 2013; 13:111.
6- Holscher CM, Haugen CE, Jackson KR, et al. Self-Reported Incident Hypertension and Long-Term Kidney Function in Living Kidney Donors Compared with Healthy Nondonors. Clin J Am Soc Nephrol 2019; 14:1493.
7- Moody WE, Ferro CJ, Edwards NC, et al. Cardiovascular Effects of Unilateral Nephrectomy in Living Kidney Donors. Hypertension 2016; 67:368.
8- Organ Procurement and Transplantation Network (OPTN)/United Network for Organ Sharing (UNOS). National data reports, transplants by donor type https://optn.transplant.hrsa.gov/data/view-data-reports/national-data/# (Accessed on March 13, 2018).
9- Muzaale AD, Massie AB, Wang MC, et al. Risk of end-stage renal disease following live kidney donation. JAMA 2014; 311:579.
10- Cherikh WS, Young CJ, Kramer BF, et al. Ethnic and gender related differences in the risk of end-stage renal disease after living kidney donation. Am J Transplant 2011;
11:1650.
11- Grams ME, Sang Y, Levey AS, et al. Kidney-Failure Risk Projection for the Living Kidney-Donor Candidate. N Engl J Med 2016; 374:411.
12- Lam NN, Lentine KL, Garg AX. End-stage renal disease risk in live kidney donors: what have we learned from two recent studies? Curr Opin Nephrol Hypertens 2014; 23:592.
13- LaPointe Rudow D, Hays R, Baliga P, et al. Consensus conference on best practices in live kidney donation: recommendations to optimize education, access, and care. Am J Transplant 2015; 15:914.
Excellent, well done
Answer: A, B C and E
A is true:
1. In the national study by NIH-USA, new-onset diabetes was rare, but approximately 3% of donors developed new-onset hypertension within 2 years of donor nephrectomy(1).
2. Kidney donation was independently associated with a 19% higher risk for hypertension, regardless of race (although baseline hypertension risk was 27% higher for blacks generally)(2).
B is true:
Most reported data suggest that proteinuria increased in the living kidney donor population, and the prevalence of microalbuminuria in living donors varied from 11.5% to 34% in different studies(3).
C is true:
Recent data support that living donors may experience a small increased risk of severe CKD and ESKD compared with healthy nondonors. For most donors, the 15-year risk of kidney failure is <1%, but for certain populations, such as young, black men, this risk may be higher.(4)
D is false:
Diabetes is rare in living kidney donor as per NIH-USA(1).
E is true:
Gestational hypertension or preeclampsia was more likely to be diagnosed in kidney donors than in matched nondonors with similar indicators of baseline health (11% in donors s v 5% in non-donors) (5).
Reference
1. Holscher CM, Bae S, Thomas AG, Henderson ML, Haugen CE, DiBrito SR, Muzaale AD, Garonzik Wang JM, Massie AB, Lentine KL, Segev DL. Early Hypertension and Diabetes After Living Kidney Donation: A National Cohort Study. Transplantation. 2019 Jun;103(6):1216-1223. doi: 10.1097/TP.0000000000002411. PMID: 30247449; PMCID: PMC6428622.
2. 9. Ibrahim HN, Foley R, Tan L et al. Long-term consequences of kidney donation. N Engl J Med 2009; 360: 459–469 [PMC free article][PubMed] [Google Scholar] [Ref list]
3. Fehrman-Ekholm I, Elinder CG, Stenbeck M et al. Kidney donors live longer. Transplantation 1997; 64: 976–978
4. Reese PP, Boudville N, Garg AX. Living kidney donation: outcomes, ethics, and uncertainty. Lancet. 2015 May 16;385(9981):2003-13. doi: 10.1016/S0140-6736(14)62484-3. PMID: 26090646.
5. Ibrahim HN, Foley R, Tan L et al. Long-term consequences of kidney donation. N Engl J Med 2009; 360: 459–469 [PMC free article][PubMed] [Google Scholar] [Ref list]
Excellent, well done
The answer is E
Donor nephrectomy does not appear to increase long-term mortality compared with controls, nor to increase ESRD risk among white donors. Within the donor population, the likelihood of post-donation chronic kidney disease, ESRD, and medical comborbidities such as hypertension and diabetes are relatively higher among some donor sub-groups, such as African Americans and obese donors, but the impact of uni-nephrectomy on the lifetime risks of adverse events expected without nephrectomy in these sub-groups is not yet defined.
5.5%associted risk of preclmpsis in some ofstudies
References1. Terasaki PI, Cecka JM, Gjertson DW, Takemoto S. High survival rates of kidney transplants from spousal and living unrelated donors. The New England journal of medicine. 1995 Aug 10;333(6):333–336. [PubMed] [Google Scholar]
2. Klein AS, Messersmith EE, Ratner LE, Kochik R, Baliga PK, Ojo AO. Organ donation and utilization in the United States, 1999–2008. Am J Transplant. 2010 Apr;10(4 Pt 2):973–986. [PubMed] [Google Scholar]
3. OTPN/HRSA. [Access Date June 1, 2011];National Data, Transplants by Donor Type.
Thank you for trying
Living donation is associated with an increased incidence of the following.
A. Hypertension- true the incidence is 10-20% post donation[1].
B. Proteinuria- True the incidence is 11,5-34% post kidney donation[2].
C. CKD- True the incidence is 10% at 44 years post donation, half of them occures after age of 64 years[3].
D. DM- False there is no increase occurrence of DM among kidney donors in comparison of general population[4].
E. Preeclampsia- True the incidence was 11% vs 5% in non donors[5]
References:
[1] Abdellaoui I, Sahtout W, Awatef A, Zallama D, Achour A. Prevalence and risk factors of hypertension following nephrectomy in living kidney donors. Saudi J Kidney Dis Transpl. 2019 Jul-Aug;30(4):873-882. doi: 10.4103/1319-2442.265463. PMID: 31464244.
[2] Einollahi B. Is proteinuria a common finding after kidney donation? Am J Transplant. 2014 May;14(5):1224-5. doi: 10.1111/ajt.12680. Epub 2014 Apr 2. PMID: 24698474.
[3] Matas AJ, Rule AD. Risk of kidney disease after living kidney donation. Nat Rev Nephrol. 2021 Aug;17(8):509-510. doi: 10.1038/s41581-021-00407-5. Epub 2021 Feb 12. PMID: 33580211; PMCID: PMC8292201.
[4] Ibrahim HN, Foley R, Tan L, Rogers T, Bailey RF, Guo H, Gross CR, Matas AJ. Long-term consequences of kidney donation. N Engl J Med. 2009 Jan 29;360(5):459-69. doi: 10.1056/NEJMoa0804883. PMID: 19179315; PMCID: PMC3559132.
[5] Garg AX, Nevis IF, McArthur E, Sontrop JM, Koval JJ, Lam NN, Hildebrand AM, Reese PP, Storsley L, Gill JS, Segev DL, Habbous S, Bugeja A, Knoll GA, Dipchand C, Monroy-Cuadros M, Lentine KL; DONOR Network. Gestational hypertension and preeclampsia in living kidney donors. N Engl J Med. 2015 Jan 8;372(2):124-33. doi: 10.1056/NEJMoa1408932. Epub 2014 Nov 14. PMID: 25397608; PMCID: PMC4362716.
Excellent, well done
I will wait for tomorrow
A- TRUE:
We identified incident hypertension as a risk factor in post-donation eGFR which merits aggressive preventive measures and careful management, as it is associated with cessation of the increase in eGFR following donation. Researchers found that, at 15 years, 8% of Caucasian non-donors and 9% of African American non-donors had hypertension compared with 23% of Caucasian donors and 42% of African American donors. Overall, kidney donation was associated with a 19% higher risk of hypertension. While researchers observed that African Americans had a greater risk (27%) than whites, the association between kidney donation and hypertension did not vary by race.
—Asch WS. Clin J Am Soc Nephrol. 2019;doi:10.2215/CJN.09650819.
Holscher CM. Clin J Am Soc Nephrol. 2019;doi:10.2215/CJN.04020419.
B-True:
Three studies compared a total of 129 donors to 59 controls on 24-h urine protein, to determine if increases in proteinuria after donation were above that possibly attributable to normal ageing (Figure 1).45,58,60 Proteinuria appeared to be increased after donation in each of these three studies, although the CIs were wide. There was no evidence of statistical heterogeneity between these three studies, suggest- ing they could have been theoretically sampled from a common distribution (w2 0.51, P 1⁄4 0.78, I2 1⁄4 0%). Thus the results were mathematically pooled, to establish a more precise estimate. The 24-h urine protein was higher in donors compared to controls an average of 11 years after donation (controls 83 mg/day, donors 147 mg/day, weighted mean difference 66mg/day, and 95% CI 24–108). This difference increased with the time from the donation (Po0.001).
–Garg, Amit X., et al. “Proteinuria and reduced kidney function in living kidney donors: a systematic review, meta-analysis, and meta-regression.” Kidney international 70.10 (2006): 1801-1810.
C-True:
Controlled studies were reviewed to determine if the initial decrement in GFR after nephrectomy was accompanied by a subsequent accelerated loss in GFR over that anticipated with normal ageing. There was no statistical heterogeneity between those where the average follow-up was at least 5 years after donation (w2 1.49, P 1⁄4 0.91, I2 1⁄4 0%) and these results were mathematically pooled (Figure 2).37,45,51,54,58,59 The pooled post-donation GFR was 10 ml/min (per 1.73 m2) lower in donors compared to controls (six studies totaling 189 controls and 239 donors; controls 96ml/min, donors 84 ml/min, weighted mean difference 10 ml/min, and 95% CI 6–15). The difference was similar across studies, irrespective of the time from the donation (P 1⁄4 0.2).
–Garg, Amit X., et al. “Proteinuria and reduced kidney function in living kidney donors: a systematic review, meta-analysis, and meta-regression.” Kidney international 70.10 (2006): 1801-1810.
D-false:
Self-reported diabetes was not significantly increased in donors when compared to healthy select controls eligible to be donors. A total of 1,029 kidney donors and 16,084 healthy controls from the HUNT study eligible for the donation from 1963 to 2008 were evaluated based on self-reported diabetes cases or on fasting glucose.
— Haugen A, et al. Poster #360. Presented at: American Transplant Congress; May 30 – June 1, 2020.
E- TRUE:
There is a small increased risk of gestational hypertension and preeclampsia in pregnancies that follow kidney donation. Kidney Disease Improving Global Outcomes (KDIGO) Clinical Practice Guideline (2017) and the 2015 American Society of Transplantation (AST) consensus conference statement recommend counselling kidney donors about this increased risk. There is no observed increase in fetal complications or eclampsia post-kidney donation. O’Keeffe et al. calculated risk pooled estimates of pregnancy-related outcomes from the Ontario and Norwegian studies [20•, 22•, 23]. The authors found that preeclampsia was twice as frequent in donors as in controls (5.9 vs. 3.1% of pregnancies) with a relative risk of 2.12 (1.06, 4.27). The relative risk for gestational hypertension was 2.27 (0.94, 5.36), low birth weight 1.70 (0.91, 3.16), and preterm birth 1.47 (0.78, 2.64) was not statistically significant between donors and non-donors.
—Shah, Pratik B., Manpreet Samra, and Michelle A. Josephson. “Preeclampsia risks in kidney donors and recipients.” Current Hypertension Reports 20.7 (2018): 1-6.
Excellent, well done
Hypertension– yes
The incidence of hypertension following unilateral nephrectomy varied widely as it has been reported at 7%-75% (1, 2, 3). Moreso, a lot of studies with different years of follow up of studies has reported that one third of all kidney donors develop hypertension (4, 5) and a meta-analysis study has shown a weighted increase in 7mmHg for systolic and 5mmHg for diastolic in those that donate kidneys. (6). Among the risk that has been found to contributes to development of hypertension after kidney donation are pre-donation blood pressure, BMI, and age. Potential donor with any of the above risk will require lifestyle adjustment and close follow up
Proteinuria: yes
In many donors there is a modest increase in urine protein excretion after unilateral nephrectomy, the majority of whom have no evidence of accelerated GFR loss over time (7, 8)). In one study, five donors with low-grade proteinuria (mean 210 mg in a 24 hr urine collection) were more likely to have significant proteinuria 20 years or more after donation (>800 mg/day), although without significant loss of kidney function (9).
CKD yes
The proportion of donors that eventually developed proteinuria or GFR < 60ml/min after the surgery are more than the general population. In a retrospective study, it was reported that 10% of the donors exceed the 300mg/day proteinuria over a subsequent decade while about 12% developed GFR <60ml/min (10)
DM yes
Although, it is expected that donor with DM should not be allowed for kidney donor. In a study done comprising of 4014 living kidney donors and average age of follow up at 17.7 years, the incidence of DM after donation was reported as 2.4%, 7.4%, and 14.5% after 10, 20, and 30 years respectively (11). Donors with DM were observed to have a higher pre-donation BMI, glucose, serum creatinine and GFR, hence the presence of these risk factor should encourage a lifestyle adjustment following donation
Preeclampsia yes
In a Canadian cohort study that followed up 595 women (85 kidney donors and 510 non donor) for a median duration of 10.9 years and observational period of 20 years. The incidence of preeclampsia was higher among donors than non-donors (11% vs 5%) (12)
1)Anderson CF, Velosa JA, Frohnert PP, et al. The risks of unilateral nephrectomy: status of kidney donors 10 to 20 years postoperatively. Mayo Clin Proc 1985. 60: 367-74
2)Eberhard OK, Kliem V, Offner G, et al. Assessment of long-term risks for living related kidney donors by 24-h blood pressure monitoring and testing for microalbuminuria. Clin Transplant 1997; 11: 415-9
3)Miller IJ, Suthanthiran M, Riggio RR, et al. Impact of renal donation. Long-term clinical and biochemical follow-up of living donors in a single center. Am J Med 1985; 79: 201-8.
4)Fehrman-Ekholm I, Elinder CG, Stenbeck M, Tyden G, Groth CG. Kidney donors live longer. Transplantation 1997; 64: 976-8.
5)Ibrahim HN, Foley R, Tan L, et al. Long-term consequences of kidney donation. N Engl J Med 2009; 360: 459-69
6)Boudville N, Prasad GV, Knoll G, et al. Meta-analysis: risk for hypertension in living kidney donors. Ann Intern Med 2006; 145: 185-96.
7)Fehrman-Ekholm I, Dunér F, Brink B, et al. No evidence of accelerated loss of kidney function in living kidney donors: results from a cross-sectional follow-up. Transplantation 2001; 72: 444-9.
8) Garg AX, Muirhead N, Knoll G, et al. Donor Nephrectomy Outcomes Research (DONOR) Network. Proteinuria and reduced kidney function in living kidney donors: a systematic review, meta-analysis and meta-regression. Kidney Int 2006; 80: 1801-10
9)Goldfarb DA, Matin SF, Braun WE, et al. Renal outcome 25 years after donor nephrectomy. J Urol 2001; 166: 2043-7.
10)AX Garg, N Muirhead, G Knoll, RC Yang et al. Proteinuria and Reduce Kidney Function in Living Kidney Donors: A Systematic Review, Meta-analysis, Meta- regression. Int. Soc Nephrol. 2006; (70): 1801-10
11) H, N Ibrahim, D.M Berglund, S Jackson et al. Renal Consequence of Diabetes after Kidney Donation. AM J Transpl. 2107; (16): 3141-48
12)Amit X. Garg, Immaculate F. Nevis, Eric McArthur, eta l. Gestational Hypertension and Preeclampsia in Living Donor. New Eng j Med. 2015; 372: 2
Thank you for trying
A 26-27 %
B microalbuminuria 11-34%, proteinuria 56%
C 1-2%
E 6.1 %
references:
1}Amit X. Garg et al.Gestational Hypertension and preeclampsia in Living Kidney Donors. N Engl J Med 2015:372:124-133.
2}Anjay Rastogi et al. Blood pressure and Living Kidney Donors:A Clinical perspective. Transplant Direct 2019 oct:5[10].
3}Arther J Matas and Hassan N.Ibrahim.The unjustified Classification of Kidney Donors as Patients with CKD: Critique and recommendations.CJASN August 2013:8{8} 1406-1413
Excellent, well done
living donation is associated with an increased incidence of the following.
A. Hypertension;
Yes
Roughly a third of kidney donors develop hypertension after donation and risk factors for its development are similar to what is seen in the general population.
B. Proteinuria;
Yes
kidney donation resulted in small increases in urinary albumin, which increased with the time after donation.
C. CKD;
Yes
Ten years after nephrectomy, donors had a GFR that was 10 ml/
min lower compared to controls.
12% of donors developed a GFR less than 60 ml/min during
follow-up.
However, after the initial decrement in GFR from the nephrectomy, there was no evidence of an accelerated loss in GFR over that anticipated with normal aging.
D. DM;
No
The prevalence of diabetes was not significantly increased in kidney donors long after donation when compared to healthy patients, according to study findings presented at the American Transplant Congress.
E. Preeclampsia;
Yes
The absolute risk of pre-eclampsia increased from ~1%–3% pre-donation to ~4%–10% post-donation (comparable to the general population).
Reference;
1-by OA Sanchez · 2018 · Cited by 45 — After a mean (SD) of 16.6 (11.9) years of follow-up, 1126 (26.8%) donors developed hypertension and 894 were receiving anti-hypertensive ..
2-Proteinuria and reduced kidney function in livingkidney donors: A systematic review, meta-analysis,and meta-regression .A Housawi 1 and N Boudville1,6 for the Donor Nephrectomy Outcomes Research (DONOR) Network 7
3- Jun 8, 2020 — The prevalence of diabetes was not significantly increased in kidney donors long after donation when compared to healthy patients, .
4- Jun 18, 2022 — The absolute risk of pre-eclampsia increased from ~1%–3% pre-donation (lower than the general population) to ~4%–10% post-donation (comparable …
Excellent, well done
A….Hypertension
There no concluded or ascertain results
So we can say No with some considerations
Healthy, well-selected donors with no known risk factors, living kidney donation does not significantly predispose them to developing hypertension postdonation
But Certain risk factors, such as being African American or Hispanic, obese, or older, are associated with higher likelihoods of developing hypertension postdonation.
REFERENCES
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6119643/#!po=42.4528
KDIGO Clinical Practice Guideline on the Evaluation and Follow-up Care of Living Kidney Donors states: “There is a need for well-designed studies to quantify the impact of live kidney donation on hypertension risk
On the other hand:
Kidney donation was independently associated with a 19% higher risk of hypertension (adjusted hazard ratio, 1.19; 95% confidence interval, 1.01 to 1.41; P=0.04); this association did not vary by race (interaction P=0.60)
REFERENCES
https://cjasn.asnjournals.org/content/14/10/1493?ijkey=96034708a30a34b96d2f1a60c88603f1e5c6dba5&keytype2=tf_ipsecsha
Donation increased the risk of hypertension after 1 year by 3.64 (95% CI 3.52 to 3.76; p<0.001).
REFERENCES
https://bmjopen.bmj.com/content/6/3/e010869?ijkey=213923ec1e24cbda18589bc0b0f752ce34216515&keytype2=tf_ipsecsha
B…..Proteinuria YES
C…..CKD (LOW GFR) YES
In eight studies which reported GFR in categories,
In controlled studies urinary protein was higher in donors and became more pronounced with time (three studies totaling 59 controls and 129 donors; controls 83mg/day, donors 147mg/day, weighted mean difference 66mg/day, 95% confidence interval (CI) 24–108).
An initial decrement in GFR after donation was not accompanied by accelerated losses over that anticipated with normal aging
(six studies totaling 189 controls and 239 donors; controls 96ml/min, donors 84ml/min, weighted mean difference 10ml/min, 95% CI 6–15; difference not associated with time after donation
Kidney donation results in small increases in urinary protein. An initial decrement in GFR is not followed by accelerated losses over a subsequent 15 years.
The pooled incidence of proteinuria was 12% (95% CI, 8-16%
REFERENCES
Proteinuria and reduced kidney function in living kidney donors: A systematic review, meta-analysis, and meta-regression
Also
recommendations of a 2015 (AST) consensus statement and (KDIGO) clinical practice guidelines , OPTN policy requires informing donor candidates that the risk of ESKD after donation may exceed that of healthy nondonors with medical characteristics similar to living kidney donors
Additionally
Compared with controls, the risk of ESKD was higher among donors (with HR adjusted for age, sex, systolic blood pressure, smoking, and body mass index [BMI] of 11.4, 95% CI 4.4-29.6).
REFERENCES
Updated
Long term risk for kidney donors
D….DM
NO but with some considerations.
The risk factors for the development of T2DM in kidney donors is similar to the general population
Living donor with family history of DMT1 has higher risk to develop DM and lesser extent without statistically significant DMT2
other risk factors
BMI > 30
Male
Age>45
REFERENCES
Diabetes after Kidney Donation H. N. Ibrahima,
E….Gestational hypertension or preeclampsia
Yes
The risk of this outcome was higher among donors than among nondonors (11% vs. 5%; odds ratio for donors, 2.4; 95% confidence
interval [CI], 1.2 to 5.0; P = 0.01).
Each component of the primary outcome was also more common among donors (odds ratio, 2.5 for gestational hypertension and 2.4 for preeclampsia).
The two groups did not differ significantly with respect to other secondary maternal or fetal outcomes.
REFERENCES
Gestational Hypertension and Preeclampsia in Living Kidney Donors Amit X. Garg,
Thank you for trying
A is true. See the replies above
A. True ( in a study, the risk of hypertension is 20% higher in kidney donors who were followed for up to 27 years post-donation compared to healthy matched non-donors).
Asch WS.CJASN October 2019, 14 (10) 1427-1429.
B. True ( in a study, 6% developed proteinuria after a median of 18 years post-donation).
Ibrahim HN, Foley RN, Reule SA, Spong R, Kukla A, Issa N, et al. Renal Function Profile in White Kidney Donors: The First 4 Decades. J Am Soc Nephrol. 2016; 27: 2885–2893.
C. True ( in a study, 35.6% had GFR below 60 at a median time of 9.2 years from donation)
Ibrahim HN, Foley RN, Reule SA, Spong R, Kukla A, Issa N, et al. Renal Function Profile in White Kidney Donors: The First 4 Decades. J Am Soc Nephrol. 2016; 27: 2885–2893.
D. True (The risk of diabetes mellitus in donors with pre-diabetes is higher than for a healthy donor with normal glucose metabolism).
Renal Consequences of Diabetes After Kidney Donation.American Journal of Transplantation.2017; 17: 3141–3148.
E. True ( in a study, over a median follow-up of 11 years, 11% develop preeclampsia post-donation).
Lentine KL, Segev DL.Understanding and Communicating Medical Risks for Living Kidney Donors: A Matter of Perspective. J Am Soc Nephrol 28: 12–24, 2017
Thank you for trying
D is wrong.
Living donation is associated with increased incidence of HTN, proteinuria, CKD and preeclampsia
A meta-analysis included observational studies of living kidney donors with follow up duration of one year or more in comparison with nondonor controls showed that donors had higher diastolic BP with no difference in systolic BP between donors and controls, authors explained it b better selection and matching of donors and control groups in more recent studies. (1)
This meta-analysis also showed that donors have higher risk for CKD and ESKD than nondonors with no evidence that living donors had higher risk for T2DM. (1)
Another meta-analysis showed that donation is associated with decreased GFR and increased proteinuria with gradually increasing rate of microalbuminuria and proteinuria at 5-year intervals after kidney donation (2)
A meta-analysis of studies evaluating rate of pregnancy complications among female donors showed that living donation is associated with significant higher risk of preeclampsia and is expected to complicate 7.4% of gestations. (3)
(1)O’Keeffe LM, Ramond A, Oliver-Williams C, Willeit P, Paige E, Trotter P, Evans J, Wadström J, Nicholson M, Collett D, Di Angelantonio E. Mid-and long-term health risks in living kidney donors: a systematic review and meta-analysis. Annals of internal medicine. 2018 Feb 20;168(4):276-84.
(2)Li SS, Huang YM, Wang M, Shen J, Lin BJ, Sui Y, Zhao HL. A meta-analysis of renal outcomes in living kidney donors. Medicine. 2016 Jun;95(24).
(3)Bellos I, Pergialiotis V. Risk of pregnancy complications in living kidney donors: A systematic review and meta-analysis. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2022 Jan 3.
its the summary of this week’s journal club
Hypertension: correct
-study showed that after 10y time post-donation, donor tend to develop hypertension 10% more nondonor matched group this percentage increase in the Prescence of some risk factors like higher BP before donation, African American and Hispanic ethnicity, obesity and elderly,
proteinuria: correct
CKD: correct
a systematic review and meta-analysis (level of evidence I) evaluating Proteinuria and reduced kidney function in living kidney donors:
after Kidney donation, small increases in proteinuria with an average 24 h urine protein was 154 mg/day which is higher than control. only 10% of donors developed proteinuria ≻ 300 mg/day and this hyperfiltration wasn’t associated with any evidence of accelerated loss of GFR.
· Regarding eGFR, even with initial loss of GFR, during long-term follow up there is no major loss in eGFR but this initial loss of GFR wasn’t followed by accelerated loss of eGFR.12 % has GFR 30 – 59 ml/min, 0.2% has GFR ≤30.
regarding ESRD: The cause of ESRD among donors was found to be mainly due to an immunological cause (SLE, ANCA vasculitis, SLE, glomerulonephritis) which may be explained by the biological relation between donor and recipients
DM: wrong
-across-sectional study (level of evidence III) The prevalence of type 2 DM in kidney donors after the donation is the same prevalence in the general population
preeclampsia: correct
a retrospective study that included 2 Adequately matched groups evaluating Gestational Hypertension and Preeclampsia in Living Kidney Donors showed that:
gestational HT & PE was more in LKD than non-donors but other maternal & fetal outcomes didn’t differ between donors & non-donors, without maternal or perinatal death.
references
1- Sanchez OA, Ferrara LK, Rein S, et al. Hypertension after kidney donation: Incidence, predictors, and correlates. Am J Transplant 2018; 18:2534.
2- Muzaale AD, Massie AB, Wang MC, et al. Risk of end-stage renal disease following live kidney donation. JAMA 2014; 311:579.
3- Lam NN, Lentine KL, Garg AX. End-stage renal disease risk in live kidney donors: what have we learned from two recent studies? Curr Opin Nephrol Hypertens 2014; 23:592.
4- LaPointe Rudow D, Hays R, Baliga P, et al. Consensus conference on best practices in live kidney donation: recommendations to optimize education, access, and care. Am J Transplant 2015; 15:914.
Excellent, well done
justify Dear All
The correct answer is A,B,C and E.
D is wrong
The winners email me to send a reward (How to read people like a book).
Hypertension is true incidence level 10% post transplant after 10year
Proteinuria is true with incidence 34%
CKD is true
DM is wrong
Preeclampsia is true with incidence 4%
A. True
BTS/RA Living Donor Kidney Transplantation Guidelines 2018
B. true
https://www.ncbi.nlm.nih.gov/books/NBK72792/#:~:text=Proteinuria%20and%20reduced,published%3A%202006.
C. True
Fehrman-Ekholm I, Norden G, Lennerling A, et al. Incidence of end stage renal disease among live kidney donors. Transplantation 2006; 82: 1646-8.
D. False
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3565834/#:~:text=Diabetes%20after%20Kidney,License%20information%20Disclaimer
E. True
Gestational Hypertension and Preeclampsia in Living Kidney Donors
n engl j med 372;2 nejm.org january 8, 2015
living donation can increase the risk of hypertension, proteinuria, and low incidence of ESKD in addition to the increased risk of post-donation preeclampsia and pregnancy-induced hypertension in female donors so all correct accept D , not associated with increased risk of DM
A is true
B is true
C is true
D is wrong because donation not risk of diabetes
E is true
true
B is true
C is true
D is wrong because donation not risk of diabetes
E is true
Living donation is associated with an increased incidence of the following.
A. Hypertension yes around 30%.
B. Proteinuria yes around 10 %.
C. CKD yes less than 1%
D. DM no
E. Preeclampsia yes ?%
“There was no patient recruitment or participation in this study but rather the study relied on prior published analyses”.
This was mentioned in the article about the study design. What do you think about the level of evidence?
Meta-analysis, Level I
meta-analysis
Level 1
Level 2: No RCTs. Cohort study
Level 3 evidence
Reterospective case control study where cases and controls of previous studies which fulfilled the criteria were cumulated and analysed through a theoretical model.
this is a population-based analysis of a large cohort with no RCT so it fit level 2 of evidence
Ø The study estimated the potential loss of life and the lifetime cumulative risk of end-stage renal disease (ESRD) from live kidney donation. Participants 40-year-old live kidney donors of both sexes and black/white race, underwent live donor nephrectomy.
Ø Main outcome and measures Potential remaining life years lost, quality-adjusted life years (QALYs) lost and added lifetime cumulative risk of ESRD from donation.
Ø Overall 0.532–0.884 remaining life years were lost from donating a kidney. This was equivalent to 1.20%–2.34% of remaining life years (The risk was higher in male and black individuals. The study showed that 1%–5% of average-age current live kidney donors might develop ESRD as a result of nephrectomy. Most of the loss of life was predicted to be associated with chronic kidney disease (CKD) not ESRD. Most events occurred 25 or more years after donation.
Ø Live kidney donation may reduce life expectancy by 0.5–1 year in most donors. The development of ESRD in donors may not be the only measure of risk as most of the predicted loss of life predates ESRD. The study identifies the potential importance of following donors and treating risk factors aggressively to prevent ESRD and to improve donor survival
Level 2
The long-term hazards are also thought to be low, particularly in low-risk donors who have undergone thorough screening. However, according to recent findings, organ donation may raise the chance of developing end-stage renal disease (ESRD) and may also increase cardiovascular mortality.
Patients who donate a kidney may be more likely to develop chronic kidney disease (CKD), which is indicated by proteinuria or a poor glomerular filtration rate (GFR) of less than 60 mL/min/1.73 m2.
Additionally, despite being screened, some donors will subsequently acquire diabetes mellitus, and they may be more likely to develop hypertension as well.
These diseases may hasten the loss of kidney function and raise the risk of ESRD
level II
The long-term hazards are also thought to be low, particularly in low-risk donors who have undergone thorough screening. However, according to recent findings, organ donation may raise the chance of developing end-stage renal disease (ESRD) and may also increase cardiovascular mortality.
Patients who donate a kidney may be more likely to develop chronic kidney disease (CKD), which is indicated by proteinuria or a poor glomerular filtration rate (GFR) of less than 60 mL/min/1.73 m2.
Additionally, despite being screened, some donors will subsequently acquire diabetes mellitus, and they may be more likely to develop hypertension as well.
These diseases may hasten the loss of kidney function and raise the risk of ESRD
This study demonstrates that donation may reduce life expectancy in average-age donors by 1%–2%, with a large portion of the mortality being linked to CKD rather than ESRD.
The study also looked at risk variables including smoking, obesity, and biological ties to the receiver that may be linked to greater risks of mortality and ESRD
Level II
The reduction in life expectancy and the risk of developing end-stage renal disease are the main concerns of a living kidney donor. Therefore, this study attempted to estimate the potential loss of life and cumulative risk of end-stage renal disease (ESRD) from donation.
This study demonstrated a shortening of donor lifespan of approximately 1%-2%, which is probably not seen in other studies due to the short follow-up period (< 20 years). However, increased mortality and decreased quality-adjusted life years (QALY) were associated with Chronic Kidney Disease (CKD) and not with End-stage Kidney Disease (ESRD), perhaps because this transition takes many years.
Another important piece of evidence was that detection of risk factors (hypertension, diabetes mellitus, and so on) and prompt intervention can help prevent end-stage renal disease and improve donor survival.
This is a level 2 study.
Introduction
Nearly 30 000 live donor kidney transplant surgeries
are performed throughout the world each year.1 The benefits to the recipients are substantial in terms of improved life expectancy and quality of life compared with dialysis or deceased donor transplantation.
Recent reports however show that there is some increase in risk of end-stage renal disease (ESRD) from donation and possibly an increase in cardiovascular mortality.5 6 Patients who donate a kidney may be at greater risk of developing chronic kidney disease (CKD) as defined by a low glomerular filtration rate (GFR) of <60 mL/ min/1.73 m2 or proteinuria.7 Furthermore, some donors will develop diabetes mellitus at a later date despite being screened and may be at higher risk of developing hypertension.
Knowing the long-term risks associated with kidney donation is important to potential donors and their providers. The focus of existing studies has been on the increase in ESRD risk resulting from kidney donation. In this study we show that donation potentially shortens life in average-age donors by about 1%–2%. This analysis shows that short-term studies (<20 years) even with appropriate normal controls are not likely to detect an adverse effect on survival.
Death during the CKD health state accounted for most of the projected increase in mortality and reduction in QALYs. Intuitively this makes some sense given that the transition from CKD to ESRD can be over many years and that progressive kidney disease is associated with graded increases in mortality. The mechanism by which low glomerular filtration rate CKD is associated with an increase in cardiovascular and all-cause mortality rate is not completely known.
It is possible that the lower glomerular filtration rate CKD as a result of donating a kidney in an ideal donor may well be different from CKD that is associated with proteinuria or diabetes mellitus. However, lower mortality risks associated with CKD were explored in the model and the results showed only a modest reduction in the percentage of total life years and QALYs projected to be lost. Although loss of life from CKD was higher compared with life lost from the ESRD health state, there were differences based on race and sex. About 78% of the loss of all QALYs from donation was associated with CKD in white female, whereas the loss was 58% in black male.
This model incorporated the probability that some donors will develop diabetes mellitus, hypertension and proteinuria at a later date, and these would impact on health (overall survival and progression to ESRD) as they do in the general population. The model could have been simplified if these risk factors for CKD and ESRD were not included in the model, but this would not reflect reality. Recent longer term observational studies have found that some donors develop diabetes mellitus and hypertension, despite being absent at the time of donation, and that these factors are subsequently responsible for ESRD.
The baseline analysis also showed that white males suffer greater added long-term ESRD risks from donation than would be anticipated. For white male the added risk of an ESRD event was 1 for every 28 donors. For black male the risk was 1 in 22. One would have expected the added risk of ESRD in white male to be less than half the added risk in black male from what is known in the general population.
The relationship between loss of remaining life years (and QALYs) and added risk of ESRD in donors is not straightforward. For example, although nearly 3.5% of white male donors are predicted to develop ESRD as a result of donation, only 0.094 QALYs or 0.43% of total remaining QALYS are lost as a result of ESRD. Calculating loss of remaining life years and QALYs helps put the risk of donation into context with other activities. The loss of life from live kidney donation is projected to be far less than smoking or mild obesity . Despite the higher initial perioperative mortality, live partial liver donation may be less risky over the long run compared with live kidney donation.
Ideally a prediction equation could be developed as was recently published for the incidence of ESRD in non-donors with differing baseline characteristics. However it was not the purpose or ability of this study to give a precise estimate of lifetime ESRD for individual donors with multiple conditions. The analysis shows that younger donors have greater added risks of ESRD and potential life years lost; however, the percentage loss of life was somewhat less compared with older cohorts. The effect of smoking and diabetes mellitus had large effects on overall survival and in lifetime risks of ESRD in donors and non-donors
The analysis suggests that counselling and interventions to reduce weight and smoking cessation are more important to both donor and non-donor and less of an argument to deny donation. Having a non-biological relationship to the recipient was associated with lower risks; however, the majority of donors are related.Donors with diabetes mellitus were at very high added risks of ESRD and death. It is interesting to point out that a 40-year-old white female with diabetes mellitus, who is otherwise well, has about the same added risk of ESRD and percentage loss of life years as a current ideal 40-year-old black male donor.
There are limitations to modelling future events. We rely on the observed rates of ESRD over 15 years in actual donors and a theoretical matched cohort to calculate lifetime outcomes.Life expectancy and the cumulative incidences of diabetes mellitus and ESRD are increasing. Using historic mortality and disease incidence rates to make accurate future lifetime projections is a significant limitation; however, similar modelling studies are used to inform current practice.
More information is required before we can truly estimate the impact of live kidney donation. Given the need for large numbers of patients and controls and long term follow-up, this risk may never be accurately measured for all age, race, sex and those with minor medical abnormalities. Given the above, estimating lifetime ESRD rates in non-donors may not be the best or only metric to inform the risk of donation.11 Greater efforts to put risk into context for potential donors in the face of uncertainty for any one individual donor. Asking donors whether they may be willing to give up between 0.5 and 1 year of life may be a better way to convey risk than giving them an estimate of their lifetime risk of ESRD. In addition the study identifies the potential importance of following donors and treating risk factors aggressively to prevent ESRD and to improve donor survival.
Level 2
Introduction :
Nearly 30 000 live donor kidney transplant surgeries are performed throughout the world each year.
The benefits to the recipients are substantial in terms of improved life expectancy and quality of life compared with dialysis or deceased donor transplantation.
The risks to the donors are generally felt to be small to modest, with a low postoperative mortality (approximately 3.1 deaths per 10 000 operations).
some increase in risk of end-stage renal disease (ESRD) from donation and possibly an increase in cardiovascular mortality.
Patients who donate a kidney may be at greater risk of developing chronic kidney disease (CKD) as defined by a low glomerular filtration rate (GFR) .
Aim of the study
were to estimate the potential loss of life as well as the added lifetime risk of ESRD in average-risk kidney donors.
Methods Model description
A USA-based Markov model was used to examine the risk of ESRD in a population of non-donors and doors.
Patient involvement in study designs.
There was no patient recruitment or participation in this study but rather the study relied on prior published analyses.
Target population :
The base case cohorts were 40-year-old patients of both sexes and white/black race from the USA. This is the mean age of live donors (median age 38) and for whom there are recent published estimates of 15-year cumulative risks of ESRD in non-donors and donors.
Main outcome measures
The health outcome of interest was remaining years of life (undiscounted).
Lifetime cumulative incidence of ESRD was also calculated.
Intervention effects
Donors in the study underwent unilateral nephrectomy. It is assumed that the nephrectomy results in a loss of GFR, and this loss of function would increase the probability of transitioning from a normal (GFR ≥60mL/min/1.7 60mL/min/1.73m2 ) to CKD.
Time horizon
The time horizon for remaining life years and QALYS was lifetime. However, for ESRD, the cumulative incidence was truncated at age 90 in keeping with other studies.
Results Baseline analysis
Differences in survival between the cohorts became apparent after 20 years or more after donation.
the remaining life years lost from donation ranged between 0.532 years for white female and 0.884 years for black female donors.
The per cent loss of life was highest in black male donors.
The per cent loss of life varied from 1.20% for white female to 2.34% for black male.
The per cent loss of total QALYs varied from 0.76% for white female to 1.51% for black male
Live kidney donation was associated with an added risk of ESRD especially among those of male sex and black race.
The added lifetime cumulative risk of ESRD varied from 1.135% in white female to 4.645% in black male (
More than 50% of all ESRD events in donors occurred 25 years or more after donation. The added ESRD even more in black male than white ones.
Donors were projected to spend 50%–85%more time with an isolated low glomerular filtration rate CKD (CKD not associated with diabetes mellitus or proteinuria) compared with non-donors.
younger patients lost more potential years of life and had potentially greater risks of ESRD given longer exposure to reduced kidney function.
However on a percentage basis, loss of life was greater in older compared with younger donors.
Life expectancies were markedly reduced and lifetime risks of ESRD increased for cohorts who were smokers or had diabetes mellitus.
Obese patients were also at increased risk but less so compared with smokers and those with diabetes mellitus. Surprisingly the absolute loss of life years was slightly less in donors who were obese or smoked compared with donors without these conditions.
Non-biological relationship to the recipient was associated with much lower loss of life years and risk of ESRD compared with those who were biologically related.
Discussion:
In this study we show that donation potentially shortens life in average-age donors by about 1%–2%. This analysis shows that short-term studies .
study also explored risk factors that can be associated with higher rate, death and ESRD such as smoking, obesity and biological relationship to the recipient.
Although loss of life from CKD was higher compared with life lost from the ESRD health state, there were differences based on race and sex. About 78% of the loss of all QALYs from donation was associated with CKD in white female, whereas the loss was 58% in black male. Given these findings, risk factor detection (hypertension, diabetes mellitus and so on) and prompt intervention could help prevent ESRD and improve donor survival.
The baseline analysis also showed that white males suffer greater added long-term ESRD risks from donation than would be anticipated. For white male the added risk of an ESRD event was 1 for every 28 donors. For black male the risk was 1 in 22. One would have expected the added risk.
Limitation of the study:
Study rely on the observed rates of ESRD over 15 years in actual donors and a theoretical matched cohort to calculate lifetime outcomes.
Using historic mortality and disease incidence rates to make accurate future lifetime projections is a significant limitation.
The study was an analysis of US donors, whereas the non-donor control population included US and international populations.
The results may not be generalised to live kidney donors from other countries where population ESRD rates are much lower.
There are many variables and transition rates included in this model and addressing uncertainty in each or combinations of variables would require a much longer paper.
The key uncertainties explored were the cumulative risks of developing ESRD and the increased mortality associated with CKD states.
The model did not include multiple stages of CKD.
Level of evidence 11.
Q4- Lifetime risks of kidney donation: a medical decision analysis
1- Please summarise this article in your own words?
Abstract
This study estimated the potential loss of life and the lifetime cumulative risk of end-stage renal disease (ESRD) from live kidney donation. The risk was higher in male and blackindividuals.
The study showed that 1%–5% of average-age current live kidney donors might develop ESRD as a result of nephrectomy. The added risk of ESRD resulted in a loss of only 0.126–0.344 remaining life years. Most of the loss of life was predicted to be associated with chronic kidney disease (CKD) not ESRD.
Most events occurred 25 or more years after donation. Reducing the increased risk of death associated with CKD had a modest overall effect on the per cent loss of remaining life years (0.72%–1.9%) and QALYs (0.58%–1.33%).
Smoking and obesity reduced life expectancy and increased overall lifetime risks of ESRD in non-donors. However the percentage loss of remaining life years from donation was not very different in those with or without these risk factors.
Conclusion Live kidney donation may reduce life expectancy by 0.5–1 year in most donors. The development of ESRD in donors may not be the only measure of risk as most of the predicted loss of life predates ESRD. The study identifies the potential importance of following donors and treating risk factors aggressively to prevent ESRD and to improve donor survival.
Introductin
The risks of HT, proteinuria, ESRD to the donors are generally small to modest, with a low postoperative
mortality (approximately 3.1 deaths per 10 000 operations).
The long-term risks are small especially in low-risk donors. New reports show that there is some increase in risk of end-stage renal disease (ESRD) from donation and possibly an increase in cardiovascular mortality. Donors may be at risk of developing chronic kidney disease (CKD) as defined by a low glomerular filtration rate (GFR) of <60 mL/ min/1.73 or proteinuria. some donors will develop diabetes mellitus at a later date and may be at higher risk of developing hypertension.
CKD is associated with an increase in risk of progression to ESRD and an increase in predialysis mortality.
Discussion
Donors should be counseled about the long-term risks associated with kidney dona tion
this study show s that donation potentially shortens life in aver age- age donors by about 1%–2%.
This analysis shows that short-term studies (<20 years) even with appropriate normal controls are not likely to detect an adverse effect on survival. Although ESRD is associated with very high mortality rates, a significant per cent of the loss of life was associated with CKD not ESRD. The study also explored risk factors that can be associated with higher rates of death and ESRD such as smoking, obesity and biological relationship to the recipient.
The per cent of patients modelled to be alive at 20 years post nephrectomy for an average-age white male donor was only 0.2% lower than a non-donor
This study shows that some donors will develop DM, HT and proteinuria at a later date, and these would impact on health (overall survival and progression to ESRD) as they do in the general population.
NEW long term observational studies have found that some donors develop DM and HT , and that these factors are subsequently responsible for ESRD.
The baseline analysis also showed that white males suffer greater added long-term ESRD risks from donation than would be anticipated. For white male the added risk of an ESRD event was 1 for every 28 donors. For black male the risk was 1 in 22.
The analysis shows that younger donors have greater added risks of ESRD and potential life years lost;but , the percentage loss of life was somewhat less compared with older cohorts. The effect of smoking and diabetes mellitus had large effects on overall survival and in lifetime risks of ESRD in donors and non-donors.
Donors with DM were at very high added risks of ESRD and death.
2- What is the level of evidence provided by this article?
Level of evidence 2
risks of kidney donation: a medical decision analysis
This study focus on survival rate of living donor post donation and risk factors leading to developing of end stage renal disease which are indirect risk of increase mortality rate. Where they do fallow up to life donor more than 15 years post donation.
The study shows decrease life expectancy to 0.5 to 1 year in comparison to non donors.
it shows little decline of estimate glomerular filtration rate with increase of age to less than 60 ml /min and increase risk of cardiovascular disease and death.
Markov model description which focus on risk factors which lead to CKD in patients who donate and compare those with non donation.
Shows donor who develop diabetes mellitus and hypertension after years from donation are associated with chronic kidney disease and ESRD in comparison to non donor but increase mortality rate in both donor and non donor are similar who had history of diabetes and hypertension and CKD because CKD risk of cardiovascular disease and increase mortality rate.
Risk factors of smoking and obesity in living donation despite good selection of healthy donor at time of donation are at high risk of hypertension and diabetes post donation and risk of chronic kidney disease and cardiovascular risk and death.
Also risk of proteinuria with hypertension more in donor rather than non donor with date.
Risk of CKD more in white female 78% and in black male around 58%.
mortality increase in CKD patients more in patients with ESRD.
The study shows the risk appeared to accelerate in white male after 25–30 years of follow-up. in comparison to black male.
The effects of diabetes and smoking on donor are high in increase risk of cardiovascular disease and reduce life expectancy in comparison to obesity donor.
living donor are less mortality in peri operative stage because improving in laparoscopically technique in removal kidney.
The analysis of study shows young donor are at high risk of reduce life expectancy.
It’s important to counselling regarding cessation of smoking and reduce weight and annually screening for diabetes and hypertension.
Level 3
risks of kidney donation: a medical decision analysis
This study focus on survival rate of living donor post donation and risk factors leading to developing of end stage renal disease which are indirect risk of increase mortality rate. Where they do fallow up to life donor more than 15 years post donation.
The study shows decrease life expectancy to 0.5 to 1 year in comparison to non donors.
it shows little decline of estimate glomerular filtration rate with increase of age to less than 60 ml /min and increase risk of cardiovascular disease and death.
Markov model description which focus on risk factors which lead to CKD in patients who donate and compare those with non donation.
Shows donor who develop diabetes mellitus and hypertension after years from donation are associated with chronic kidney disease and ESRD in comparison to non donor but increase mortality rate in both donor and non donor are similar who had history of diabetes and hypertension and CKD because CKD risk of cardiovascular disease and increase mortality rate.
Risk factors of smoking and obesity in living donation despite good selection of healthy donor at time of donation are at high risk of hypertension and diabetes post donation and risk of chronic kidney disease and cardiovascular risk and death.
Also risk of proteinuria with hypertension more in donor rather than non donor with date.
Risk of CKD more in white female 78% and in black male around 58%.
mortality increase in CKD patients more in patients with ESRD.
The study shows the risk appeared to accelerate in white male after 25–30 years of follow-up. in comparison to black male.
The effects of diabetes and smoking on donor are high in increase risk of cardiovascular disease and reduce life expectancy in comparison to obesity donor.
living donor are less mortality in peri operative stage because improving in laparoscopically technique in removal kidney.
The analysis of study shows young donor are at high risk of reduce life expectancy.
It’s important to counselling regarding cessation of smoking and reduce weight and annually screening for diabetes and hypertension.
This evidence level 2
A. true.
B. true
C. true
D. true
E. true
Objective
This study estimated the potential loss of life and the lifetime cumulative risk of end-stage renal disease (ESRD) from live kidney donation.
Design Markov medical decision analysis.
Setting USA.
Participants 40-year-old live kidney donors of both sexes and black/white race.
Intervention Live donor nephrectomy.
Main outcome and measures Potential remaining life years lost, quality-adjusted life years (QALYs) lost and added lifetime cumulative risk of ESRD from donation.
Results
Conclusion
Limitation of study:
Level of evidence
Level III
The study were conducted to estimate the potential loss of life as well as the added lifetime risk of ESRD in average risk kidney donors.
Target population: the base case cohorts were 40 year-old patients of both sexes and white/black race from the USA.
This study showed that donation potentially shortens life in average age donors by about 1% to 2% . The risk was higher in male and black individuals.
This analysis showed that short term studies < 20 years even with appropriate normal controls are not likely to detect an adverse effect on survival.
The study showed that 1% to 5% of average age current live donors might develop ESRD as a result of nephrectomy
A significant percent of the loss of life was associated with CKD not ESRD. The study showed that smoking and obesity were associated with higher rates of death and ESRD.
Conclusion: live kidney donation may reduce life expectancy by 0.5 – 1 year in most donors. The development of ESRD in donors may not be the only measure of risk as most of the predicted loss of life predates ESRD .so the donors should be followed up and any risk factors should be considered and treated to prevent ESRD and to improve donor survival.
Level of evidence 2
This is a retrospective cohort study – level IIb.
It used a model called Markov medical decision analysis using the American position at age 40 including gender or ethnicity. The intention of the study is to define whether there is a difference in the prognosis of living donors who underwent nephrectomy based on sex or ethnicity. The main objectives were to assess years of potential life lost, adjusted loss of years lost, and cumulative risk of end-stage renal disease.
The analysis was performed in comparison with a population with the same characteristics as the donor, having the healthy behavior of a potential donor.
The results showed that the difference in survival in the cohorts only occurred after 20 years after donation. Men of black ethnicity had the worst survival rates, including considering QUALYs. The same occurs with ESRD, where most cases occurred within 25 years or more of donation.
Even in different sexes, black women (1.74%) are at higher risk than white men (1.39%) when compared to black men (1.9%). In other analyses, young people were at greater risk of donating. Diabetes and smoking are other risk factors, the former being the worst. Obesity may have some related potential, but it is inferior to the previous two.
This study showed that the loss of life potential ranges from 1 to 2%, being more related to chronic kidney disease and not an end-stage renal disease. These risks were different depending on ethnicity (whites 1 in 28 / blacks 1 in 22). This study suggests smoking cessation is associated with weight loss in those with a BMI greater than 30.
The benefit of renal transplantation is well known as it improve survival of the recipients, but the life long donor risk supposed to be small in low risk donors after screening. But recent studies show that increased risk of ESRD & CVD in donors & some may develop HT or DM years after donation which increase the risk of eGFR reduction.
This meta-analysis of systemic review found :
Limitations of the study:
Level 1 study
# Please summarise this article in your own words
*The aim of the study:
To estimate the potential loss of life and the lifetime cumulative risk of (ESRD) from live kidney donation.
# Introduction:
*About 30 000 live donor kidney transplant surgeries are done throughout the world per year,
* The benefits of kidney transplant surgeries to the recipients are substantial in terms of improved life expectancy and quality of life compared with dialysis or deceased donor transplantation.
*The risks to the donors are generally felt to be small to modest, with a low postoperative mortality *Patients who donate a kidney may be at greater risk of developing (CKD) as defined by a low (GFR) of <60 mL/ min/1.73 m2 or proteinuria, some donors will develop diabetes mellitus at a later date despite being screened and may be at higher risk of developing hypertension.
* These conditions could accelerate the loss of kidney function and increase the risk of ESRD.
#Methods
#Model description
*A USA-based Markov model was used to examine the risk of ESRD in a population of non-donors and donors.
#The following are the key assumptions for the model:
*The incidence of ESRD rates are higher in donors compared with non-donors.
*In both donors and non-donors ESRD will be associated with high mortality rates.
* Donor and non-donors transition through a CKD state for at least 1 year before developing ESRD.
* As the ESRD rates are high in donors compared with non-donors, so there have been
an increase in the rate of transition to and time spent in CKD states.
* Nephrectomy in donors will quantitatively reduce overall patient kidney function.
(donors will have a greater risk of falling below a GFR threshold of 60 mL/min/1.73 m2 compared with non-donors).
* Cohorts are assumed to be free of HTN, DM and proteinuria at donation, but they are risky to developing these conditions whether they donate or not, and these will impact patient survival and loss of kidney function in both donors and non-donors.
*CKD states will be associated with higher mortality rates as in the general population.
* Model transition rates from normal to CKD states could be empirically derived to reproduce observed 15-year cumulative incidence rates for ESRD in donors and non-donors and can be used to subsequently project lifetime cumulative risks of ESRD.
# Results:
*Overall 0.532–0.884 remaining life years were lost from donating a kidney. This was equivalent to 1.20%–2.34% of remaining life years (or 0.76%–1.51% remaining QALYs).
*The risk was higher in male and black individuals.
The study showed that 1%–5% of average-age current live kidney donors might develop ESRD as a result of nephrectomy. The added risk of ESRD resulted in a loss of only 0.126–0.344 remaining life years. Most of the loss of life was predicted to be associated with chronic kidney disease (CKD) not ESRD.
*Most events occurred 25 or more years after donation. Reducing the
increased risk of death associated with CKD had a modest overall effect on the per cent loss of remaining life years (0.72%–1.9%) and QALYs (0.58%–1.33%).
*Smoking and obesity reduced life expectancy and increased overall lifetime risks of ESRD in non-donors. However the percentage loss of remaining life years from donation was not very different in those with or without these risk factors.
# The strength and limitation:
*The study projects the long-term risk of donating a kidney, including loss of life and the added risk of end-stage renal failure.
* These findings help quantify and communicate risk to potential donors and convey the importance of lifelong follow-up in actual donors.
* The study uses evidence of over 15 years of follow up in actual live kidney donors and healthy controls.
*The ability to predict lifetime outcomes from 15- year follow-up in donors of all ages and medical conditions is a limitation.
# Conclusion
Live kidney donation may reduce life expectancy by 0.5–1 year in most donors. The
development of ESRD in donors may not be the only measure of risk as most of the predicted loss of life predates ESRD. The study identifies the potential importance of following donors and treating risk factors aggressively to prevent ESRD and to improve donor survival.
# What is the level of evidence provided by this article?
It is cohort study, prospective study level 2.
Summary
· Many studies suggested that donors are at higher risk of proteinuria, development of CKD, HTN, DM, and cardiovascular mortality when compared to non-donors.
· Risk factors for those complications are male gender and black races.
· There is a definite risk of decrease life by Donation, but still of little significance (about 0.5-1 year).
· Also risk of ESRD is present especially in obese, smoker and biologically related donor.
· Conclusion
· However, it is still a minimal risk and the procedure should continue.
· Healthy Lifestyle as weight reduction, smoking cessation and regular follow up can alter this outcome
· Level of evidence: II
· There is some evidence that there is some increase in risk of ESRD from donation and possibly an increase in cardiovascular mortality.
· Donors could be at greater risk of developing CKD as defined by a low GFR of <60mL /min / 1.73 m2 or proteinuria
· Some donors also can develop DM and have higher risk of HTN post donation
Objectives of the study
· estimate the potential loss of life as well as the added lifetime risk of ESRD in average-risk kidney donors
Methods
Model description
the key assumptions for the model:
· ESRD rates are increased in donors compared with non-donors
· ESRD in both donors and non-donors will be associated with high mortality rates
· Donor and non-donors transition through a CKD state for at least 1year before developing ESRD
· The assumed there must have been an increase in the rate of transition to and time spent in CKD states
· Post nephrectomy, donors will have a greater risk of falling below a GFR threshold of 60mL/min/1.73m2 compared with non-donors.
· At donation, cohorts are free of DM, HTN, and proteinuria. But they are at risk to develop thise conditions, even if they are not donors
· CKD states will be associated with higher mortality rates as in the general population
· CKD progression to ESRD is increased by age
Target population
The base case cohorts were 40-year-old patients of both sexes and white/black race from the USA
Results
· The differences in survival between the cohorts became apparent after 20 years or more after donation
· loss of life varied from 1.20% for white female to 2.34% for black male.
· Live kidney donation was associated with an added risk of ESRD especially among those of male sex and black race
· The added lifetime cumulative risk of ESRD varied from 1.135% in white female to 4.645% in black male
· More than 50% of all ESRD events in donors occurred 25 years or more after donation
· The added ESRD events tended to occur earlier in black male compared with white male
· In a sensitivity analysis, the added cumulative risks of developing ESRD were predicted to be lower in the ‘ideal’ cohort especially for white male and female compared with the base case analysis
· Donors were predicted to live 50%–85%more time with low GFR CKD without DM or proteinuria compared with non-donors
· Donors with DM or smokers have reduced Life expectancies and increased lifetime risks of ESRD
· Obese donors also had more risk but less than smokers and diabetics
· Strangely the absolute loss of life years was slightly less in obese or smoking donors compared with donors without these conditions.
· Diabetic donors had the greatest loss of life years and increased risk of ESRD
· Non-biological related donors had much lower loss of life years and risk of ESRD than biologically related
CONCLUSION
· Donation potentially shortens life in average-age donors by about 1%–2%
· Although ESRD is associated with very high mortality rates, a significant per cent of the loss of life was associated with CKD not ESRD
· Smoking and obesity may have a role in the mortality and progression to ESKD
· Larger numbers of patients and controls and long term follow-up are needed to accurately measure the risk for all age, race, sex and those with minor medical abnormalities
Limitation of the study:
· Follow up of donors for 15 years not enough to predict lifetime outcome
· The study was an analysis of US donors, whereas the non-donor control population included US and international populations
· The results cannot be widely applicable to live kidney donors worldwide where incidence of ESRD is different
· The model did not include multiple stages of CKD
· Since donors eventually have a greater risk of entering into a more advanced CKD state, this analysis may have underestimated the overall net loss of life years from nephrectomy
· Author assumed that the relative risks between white and black of both sexes with a biological relationship were the same
What is the level of evidence provided by this article?
observational longitudinal cohort study evidence level 2
The number of living donation in increasing with time , the effect of transplantation on the patient and the subsequent improving in the quality of life and increase life expectancy is well studied ,
in this study they interested to know the long term effect on donation in the donors such as ESRD , CKD , protienurea , HTN … etc
results :
highest in black male donors
Living donation is associated with an increased incidence of the following.
A. Hypertension : yes
B. Proteinuria : yes
C. CKD : yes
D. DM : no
E. Preeclampsia : yes
Summary:
This study was conducted to estimate the cumulative risk of ESRD and risk of loss of life post kidney donation. And include living kidney donors aged 40 years and follow up more than 15 years.
This study showed:
-Remaining years of life and QALYs: Loss of 0.5-0.8 year from life (equivalent to 1.2-2.3% of remaining life).
-Donation potentially reduced life by 1-2% in a 40 year old donor.
-Males and African-Americans showed higher risk of life loss.
-Loss of life is mostly due to CKD.
-ESRD incidence: 1-5%. Added risk of ESRD reduced 0.1-0.3years from remaining life. More in black males and less in white females
-50% ESRD occurred more than 25 years post-donation.
-DM, smoking, obesity, and organ donation were associated with higher risk of life loss and ESRD.
Level of evidence: level 2
Risk for donors after nephrectomy is small provided, they are of low risk and are followed regularly for any complications or new development of diabetes or hypertension.
Studies have shown that kidney donors are at high risk of development of CKD, ESRD and cardiovascular complications while can develop HTN, DM on long term too.
Study has shown the 15 years and lifetime risk of developing ESRD in potential non donors that candidates with minor medical comorbidities, male, and those of black race are at higher risk.
This cohort study evaluating the possible death and the added lifetime risk of ESRD in average risk kidney donors.
Markov model was used to evaluate the risk of ESRD in non-donors and donors.
This model supposed that.
· ESRD will be more associated with donors than non-donors and that both candidates with ESRD will have high mortality rate.
· Both candidates will go through CKD before reaching ESRD
· Nephrectomy will be associated with low GFR threshold of 60mL/min/1.73m2 compared with non-donors.
· Candidates are supposed to be disease free and can be at high risk of developing DM ,HTN , or proteinuria later on if donated or if did not donate along with their impact on survival and renal function
· CKD cases have high mortality risks
· Transition rates from normal to CKD states
The model can derive to reproduce observed 15-year cumulative incidence rates for ESRD in donors and non-donors.
The study included data published before on the estimates of 15-year cumulative risks of ESRD in non-donors and donors for 40 years old candidates of both sexes and races.
QALYs were calculated and lifetime cumulative incidence of ESRD was also calculated.
Result:
· Survival variation between the cohorts was noticed after 20 years or more after donation.
· The per cent loss of life was highest in black male donors.
· The percentage loss of life ranged from 1.20% for white female to 2.34% for black male.
· The % loss of total QALYs varied from 0.76% for white female to 1.51% for black male.
· The added lifetime cumulative risk of ESRD ranged from 1.135% in white female to 4.645% in black male.
· Most ESRD events in donors happened 25 years or more after donation.
· Donors experienced 50%–85%more time with an isolated low eGFR CKD compared with non-donors.
· Overall percentage loss of remaining life years of 1.39%, 0.72%, 1.9% and 1.74% for white male, white female, black male, and black female, respectively.
· Young were subjected to more loss of years of life and higher liability of ESRD development due to longer time of exposure to low eGFR, on the other hand on percentage loss of life was greater in older donor,
· ESRD and lesser life expectancy were associated with smoking, obesity and DM mean while obese smoker donors had little less risk than non-obese non-smoker donors.
· Diabetic donors had the greatest loss of life years and increased risk of ESRD. Life loss and ESRD were higher in biologically related donors to recipients.
This study showed that donation can shorten life in average age donors by 1%–2% and short-term studies even with suitable controls are unable to detect an adverse effect on survival. CKD not ESRD was associated with significant percentage of life loss. Risk factors associated with increased risk of ESRD and death as smoking, obesity and DM were assessed. Meanwhile it is not clear whether donation has a significant impact on death risk or not. The possible percentage to be alive after 20 y of donation for average aged white donor is 0.2% less than matched non donor candidate.
The model overestimated the lifetime ESRD predictions in non-donors. White males had long-term ESRD higher risks from donation than would be supposed could be due to longer life expectancy. Death due to donation is much less than death due to smoking or obesity. Live partial liver donation seems to be less risky over time than live renal donation although the former has higher perioperative mortality risk . Smoking and diabetes mellitus had great impact on overall survival and in lifetime risks of ESRD in donors and non-donors. The effects were less in obese donors compared with donors who were smoking or had diabetes mellitus.
Limitation as ESRD and DM risk are increasing.
· There were many variables and transitions included in the model but CKD stages were not included.
· The ability to predict lifetime prognosis from 15- year follow-up of donors of all ages and medical
· conditions is a limitation.
· Informing the donors about the possibility of giving up between 0.5 and 1year of life may be a better way to explain the risk than giving them an estimate of their lifetime risk of ESRD
· Long term follow up of donors is essential to avoid risks
Level 2 cohort study
summary of the article
Nearly 30 000 live donor kidney transplant surgeries are performed throughout the world each year.
in low-risk donors long-term risks are felt to be small and on very long time .
Recent reports showed there is some increase in risk of ESRD and cardiovascular mortality from donation .
Kidney donors are at greater risk of developing chronic kidney disease (CKD) as defined by a low glomerular filtration rate (GFR) of <60mL/ min/1.73m2 or proteinuria.
some donors may become diabetic or hypertensive later date despite being screened which might accelerate the loss of kidney function and increase predialysis mortality.
▪︎Key assumptions for the study model
–high incidence of ESRD in donors compared with non-donors.
– ESRD is associateed with high mortality rates In all groups.
– CKD state for at least 1 year before developing ESRD in both groups .
– Nephrectomy in donors will quantitatively reduce overall patient kidney function.
– as kidney function declines over time in most individuals, donors will have higher risk of lower eGFR below threshold of 60 mL/min/1.73 m2 compared with non-donors.
-Cohorts are assumed to be free of hypertension, diabetes mellitus and proteinuria at donation, and risk of developing these conditions whether they donate or not, and these will impact patient survival and loss of kidney function in both donors and non-donors.
-Given that some individuals may be at higher or lower risks of diabetes mellitus and proteinuria, smoke or are obese, we examined these in additional sensitivity analyses.
-Diabetes mellitus in non-donors would follow the same pattern (increasing rates with age) as in the general population.
– CKD states will be associated with higher mortality rates as in the general population.
– Model transition rates from normal to CKD states could be empirically derived (by working backwards) to reproduce observed 15-year cumulative incidence rates for ESRD in donors and non-donors and can be used to subsequently project lifetime cumulative risks of ESRD.
▪︎The base case cohorts were 40-year-old patients of both sexes and white/black race from the USA.
for whom there are recent published estimates of 15-year cumulative risks of ESRD in non-donors and donors.
▪︎Main outcome measures
-outcome of interest was remaining years of life .
-life years were scaled by measures of quality and discounted at a 3% rate of time preference to calculate QALYs.
-Lifetime cumulative incidence of ESRD was also calculated.
-The lifetime estimates of ESRD were found to be higher in non-donors than published estimates, since this model incorporated the possibility that some participants might develop diabetes mellitus and proteinuria.
– Ideal non-donors had lower incidence of diabetes mellitus, proteinuria and rates of transition to CKD to match projected lifetime ESRD risks rather than calibrating to 15-year ESRD risks.
-Non-donors were assumed to have lifetime cumulative ESRD risks of 0.43% , 0.29% , 1.00% and 0.85% for white male, white female, black male and black female, respectively.
– mortality associated with CKD is an important driver of life years lost.
▪︎Results
-Differences in survival between the cohorts became apparent after 20 years or more after donation.
-the remaining life years lost from donation ranged between 0.532 years for white female and 0.884 years for black female donors while the highest percent was in black male donors.
-The percent loss of life varied from 1.20% for white female to 2.34% for black male. The percent loss of total QALYs varied from 0.76% for white female to 1.51% for black male.
-The study showed that 1%–5% of average-age current live kidney donors might develop ESRD.
-The added risk of ESRD resulted in a loss of only 0.126–0.344 remaining life years.
-Most of the loss of life was predicted to be associated with (CKD) not ESRD.
-Death during the CKD health state accounted for most of the projected increase in mortality and reduction in QALYs
-Smoking and obesity and biological relationship to the recipient are risk factors associated with reduced life expectancy and increased overall lifetime risks of ESRD in non-donors.
– Live kidney donation may reduce life expectancy by 0.5–1 year in most donors.
-The relationship between loss of remaining life years (and QALYs) and added risk of ESRD in donors is not straightforward.
-The analysis suggests that counselling and interventions to reduce weight and stop smoking are more important to both donor and non-donor and less of an argument to deny donation.
-Having a non-biological relationship to the recipient was associated with lower risks; however, the majority of donors are related
More information is required before we can truly estimate the impact of live kidney donation.
Given the need for large numbers of patients and controls and long term follow-up, estimating lifetime ESRD rates in non-donors may not be the best or only metric to inform the risk of donation.
▪︎What is the level of evidence provided by this article?
The level of evidence II
A. Correct: risk of hypertension in donors compared to non donors is 5-20%.
B. Correct : post donation proteinuria occurs with incidence of11.5-34% .
C. Correct: post donation CKD incidence is 10% ;relative risk of ESRD is eight times more than controls.
D. False :no evidence of increased post donation DM.
E .Correct: Post donation preeclampsia has incidence of 11% compared to 5% in non donors; with incidence of gestational hypertension of 5 % in donors compared to 2 % for non donors.
Introduction
Around 30000 kidney donations is done yearly worldwide. The expected benefit is improving survival and quality of life for the recipients. However, there is a risk for the donor although it is small. With post operative mortality of around 3 per 10000 surgeries. On the long term also, the risk is estimated to be low, but some recent reports showed that risk of ESRD is increased.
The objectives of this study were to estimate the potential loss of life as well as the added lifetime risk of ESRD in average- risk kidney donors.
Methods
Model description
A USA-based Markov model was used to examine the risk of ESRD in a population of non-donors and donors.
Target population
The base case cohorts were 40-year-old patients of both sexes and white/black race from the USA. This is the mean age of live donors (median age 38) and for whom there are recent published estimates of 15-year cumulative risks of ESRD in non-donors and donors.
Main outcome measures
The health outcome of interest was remaining years of life.
Intervention effects
Donors in the study underwent unilateral nephrectomy. It is assumed that the nephrectomy results in a loss of GFR, and this loss of function would increase the probability of transitioning from a normal (GFR ≥60 mL/min/1.73 m2) kidney function heath state to CKD.
Results
Differences in survival starts to appear after 20 years or more from donation. The remaining life years lost from donation ranged between 0.532 years for white female to 0.884 years for black female donors.
The per cent loss of life was highest in black male donors. The per cent loss of life varied from 1.20% for white female to 2.34% for black male. The per cent loss of total QALYs varied from 0.76% for white female to 1.51% for black male. Those with diabetes has more loss than others.
The added lifetime cumulative risk of ESRD varied from 1.135% in white female to 4.645% in black male. This translated to one added ESRD event for every 88 white female donors or one added ESRD event for every 22 black male donors.
Discussion
This study showed that the remaining life lost because of donation range from 1-2%. It is higher in black male and lowest in white female. If we compared this with life lost due to smoking and mild obesity the late are costing more. Compared with live part of liver donation, despite higher perioperative mortality in liver donation 1.7 per 1000 versus 0.31 per 1000 kidney donations, there is no long-term life loss in the liver donors.
This study also highlighted the importance of long time follow up, as the risk of CKD and ESRD appears after 25years. This means that studies with shorter duration will easily missed this risk.
Limitations
1. Limitation of modelling future events.
2. We rely on the observed rates of ESRD over 15 years in actual donors and a theoretical matched cohort to calculate lifetime outcomes.
3. Life expectancy and the cumulative incidences of diabetes mellitus and ESRD are increasing.
4. Using historic mortality and disease incidence rates to make accurate future lifetime projections. however,
5. The study was an analysis of US donors, whereas the non-donor control population included US and international populations.
Level 11
Based on this article, it provides information about the lifetime risk of kidney donation. The study was conducted in the United States using Marlov model to examine the risk of ESRD in a population of non-donor and donors.
The model key information used are:
1) ESRD are found more frequently in donors than non-donors
2) Once both groups have ESRD they have high mortality rate
3) The transitional stage in donor and non-donors to CKD to ESRD may be a timeline of 1 year.
4) Kindy donation with time will lead to decrease in kidney function and the donor will be at increased risk of kidney failure or decrease GFR.
Based on the study, it was found that:
1) Donations reduce life by 1-2 % in a 40-year-old donor
2) Male patients and African American are at a higher risk to loss of life.
3) CKD is the main reason for loss of life
4) After 25 years post donation there is 50% chance of having ESRD.
Certain risk factors have associated risk of increase ERSD and as such life loss and are as follows:
1) DM
2) Obesity
3) Smoking
The limitation of this study was that it lacks control group, only a small number of donors were included, the follow-up was a short time and different stages of CKD were not included.
The level of evidence in the study was 3
1-Summary ofLifetime risks of kidney donation: a medical decision analysis Aim of this study were estimate the potential loss of life as well as the added life time risk of ESRD in average age risk kidney donors .
Methods:
Model description AUSA- based Markov, model was used to examine the risk of ESRD in a population of non donors and donor.
There was no patients in this study but rather than study relied on prior published analysis.
The target population were 40 years old patients of both sex and white /black race from USA.
This study ,main outcome measure health out come of life and incidence of ESRD in donors.
All donors in the study had unilateral nephrectomy which result in a loss of GFR and subsequent develop of CKD .
Analysis, design and outcomes
Primary outcome of the same population of healthy potential donors were the change of their remaining life years ,QALYS and development of ESRD.
Donors were assumed to have 15 years cumulative ESRD risk of 0.34 ,0.15 % 0.96 % and 0.59% for white male ,white female ,black male and black female .
Isolated CKD (no proteinuria ,nor DM) in donors compared with non-donors was not associated with an increase in mortality.
Others sensitivity analysis include age at donation ,smoking status ,higher BMIA new onset DM and biological relationship to recipient were explored.
Result
Live kidney donation was associated with an added risk of ESRD especially among those of male sex and black race .
More than 50% of all ESRD events in donors occurred 25 years or more after donation.
Younger had greater risk of ESRD .
Loss of life was greater in older compared with younger donors.
The absence loss of life years was slightly less in donors who were obese or smoke compared with donors without these condition.
Discussion
In this study we show that donation potentially shorten life in average age donors 1% -2%.
Shorten of the time of this analysis(<20years) are unlikely to detect and decrease effect on survival .
Based on current literature it is unclear whether is a significant risk of death from donation but studies had small numbers .
Many of these risk factors develop years after donation .
Short term follow up of kidney donors may be inadequate obesity and smoking are risk factors that might develop after donation.
The burden of ESRD is ever growing and organ shortage is a world wide problem.Convincing a living donor is another issue faced by all of us in our daily practice.The question and anxiety of potential donors is always to know what kind of risks donation would pose to them and how it is going to effect their future life.
Kiberd and collaegues used a USA-based Markov model to examine the risk of ESRD in a population of non-donors and donors.
The following are the key assumptions for the model:
ESRD rates are increased in donors compared with non-donors
ESRD in both donors and non-donors will be associat- ed with high mortality rates.
Donor and non-donors transition through a CKD state for at least 1 year before developing ESRD.
Since ESRD rates are increased in donors compared with non-donors, we assumed there must have been
an increase in the rate of transition to and time spent
in CKD states.
Nephrectomy in donors will quantitatively reduce overall patient kidney function. Given that kid- ney function declines over time in most individu- als, donors will have a greater risk of falling below a GFR threshold of 60 mL/min/1.73 m2 compared with
non-donors.
Cohorts are assumed to be free of hypertension, dia- betes mellitus and proteinuria at donation. However they are at risk of developing these conditions wheth- er they donate or not, and these will impact patient
survival and loss of kidney function in both donors
and non-donors. Given that some individuals may be at higher or lower risks of diabetes mellitus and proteinuria, smoke or are obese, we examined these in additional sensitivity analyses. Diabetes mellitus in non-donors would follow the same pattern (increas- ing rates with age) as in the general population even though absolute rates might be lower (if initially screened to be negative).
CKD states will be associated with higher mortality rates as in the general population, but the magnitude of this effect was examined in additional sensitivity
analyses.
Model transition rates from normal to CKD states could be empirically derived (by working backwards) to reproduce observed 15-year cumulative incidence rates for ESRD in donors and non-donors and can be
used to subsequently project lifetime cumulative risks of ESRD. CKD in non-donors would follow the same pattern (increasing rates with age) as in the general population but at overall lower rates.
Main outcome and measures
Potential remaining life years lost,
quality-adjusted life years (QALYs) lost
and added lifetime cumulative risk of ESRD from donation.
STRENGTH AND WEAKNESS
The study projects the long-term risk of donating a kidney, including loss of life and the added risk of end-stage renal failure.
These findings help quantify and communicate risk to potential donors and convey the importance of lifelong follow-up in actual donors.
The study uses evidence of over 15 years of follow- up in actual live kidney donors and healthy controls.
The ability to predict lifetime outcomes from 15- year follow-up in donors of all ages and medical
conditions is a limitation.
RESULTS
Overall 0.532–0.884 remaining life years were lost from donating a kidney.
This was equivalent to 1.20%–2.34% of remaining life years (or 0.76%–1.51% remaining QALYs).
The risk was higher in male and black individuals. The study showed that 1%–5% of average-age current live kidney donors might develop ESRD as a result of nephrectomy.
The added risk of ESRD resulted in a loss of only 0.126–0.344 remaining life years.
Most of the loss of life was predicted to be associated with chronic kidney disease (CKD) not ESRD.
Most events occurred 25 or more years after donation.
This is an observational longitudinal cohort study with population data as controls.
Therefore, this article provides level 2 evidence. (Thanks Dr Sharma)
This study was conducted in the USA to estimate the cumulative risk of ESRD and risk of loss of life post kidney donation.
Included subjects: living kidney donors aged 40 years.
Follow up: more than 15 years.
Methods: reviewing published studies and analysis using Markov model.
Results:
1- Remaining years of life and QALYs: Loss of 0.5-0.8 year from life (equivalent to 1.2-2.3% of remaining life).
2- Donation potentially reduced life by 1-2% in a 40 year old donor.
3- Males and African-Americans showed higher risk of life loss.
4- Loss of life is mostly due to CKD.
5- ESRD incidence: 1-5%. Added risk of ESRD reduced 0.1-0.3years from remaining life (maximum for black males and least for white females).
6- 50% ESRD occurred more than 25 years post-donation.
DM, smoking, obesity, and organ donation were associated with higher risk of life loss and ESRD.
Limitations:
1- Small numbers of donors in the included studies.
2- short-term follow-up (<30 years).
3- Lack of controls.
4- The study group was US donors, while control population included international population.
5- Multiple stages of CKD were not included.
Level III evidence
l of evidence (LOE)
Description
Level I
Evidence from a systematic review or meta-analysis of all relevant RCTs (randomized controlled trial) or evidence-based clinical practice guidelines based on systematic reviews of RCTs or three or more RCTs of good quality that have similar results.
Level II
Evidence obtained from at least one well-designed RCT (e.g. large multi-site RCT).
Level III
Evidence obtained from well-designed controlled trials without randomization (i.e. quasi-experimental).
Level IV
Evidence from well-designed case-control or cohort studies.
Level V
Evidence from systematic reviews of descriptive and qualitative studies (meta-synthesis).
Level VI
Evidence from a single descriptive or qualitative study.
Level VII
Evidence from the opinion of authorities and/or reports of expert committees.
A retrospective case-control study (level III) in which there was no patient recruitment or participation in this study instead the study relied on prior published analyses evaluating quality-adjusted life years lost related to donation and the cumulative lifetime risk of end-stage renal disease (ESRD) in 40years old kidney donors of both sexes and white/black race from the USA.
Based on the hypothesis that:
1] The risk of CKD is higher after donation due to a decrease in renal mass
2] complications related to donation like hypertension and DM which potentiate the risk of deterioration.
Methods:
No patient recruitment or participation in this study instead the study relied on prior published analyses OF 40-year-old life kidney donors of both sexes, black and white races. All patients Were followed for 15 years after kidney donation and then compared to a controlled cohort.
Results:
Lifetime risks of kidney donation: a medical decision analysis
_____________________€
☆Introduction
▪︎The risks to the kidney donors after surgery are small to modest, with a low postoperative mortality. ▪︎The long-term risks are also presumed to be small especially in low-risk donors who are adequately screened.
☆Risks of kidney donation:
1.CKD (low GFR of <60mL/ min/1.73m2 or proteinuria) which may progress to ESRD
2. Increase in cardiovascular mortality.
3. DM
4. Hypertension.
▪︎Donors with minor medical abnormalities, men and individuals of black race had greater 15-year and lifetime risks of ESRD.
☆The objectives of the study
To estimate the potential loss of life as well as the added lifetime risk of ESRD in average-risk kidney donors.
☆Results:
▪︎Overall 0.532–0.884 remaining life years were lost from donating a kidney.
▪︎The risk was higher in male and black individuals. ▪︎The study showed that 1%–5% of average-age current live kidney donors might develop ESRD as a result of nephrectomy.
▪︎The added risk of ESRD resulted in a loss of only 0.126–0.344 remaining life years.
▪︎Most of the loss of life was predicted to be associated with CKD not ESRD.
▪︎Most events occurred 25 or more years after donation. Reducing the increased risk of death associated with CKD had a modest overall effect on the per cent loss of remaining life years (0.72%–1.9%) and QALYs (0.58%–1.33%).
▪︎Smoking and obesity reduced life expectancy and increased overall lifetime risks of ESRD in non-donors. However the percentage loss of remaining life years from donation was not very different in those with or without these risk factors.
☆Strength of this study:
1.The study projects the long-term risk of donating a kidney, including loss of life and the added risk of end-stage renal failure.
2.The findings help quantify and communicate risk to potential donors and convey the importance of lifelong follow-up in actual donors.
3.The study uses evidence of over 15 years of follow-up in actual live kidney donors and healthy controls
☆Limitations:
The ability to predict lifetime outcomes from 15- year follow-up in donors of all ages and medical conditions.
☆Conclusion
▪︎Live kidney donation may reduce life expectancy by 0.5–1 year in most donors.
▪︎The development of ESRD in donors may not be the only measure of risk as most of the predicted loss of life predates ESRD.
▪︎The study identifies the potential importance of following donors and treating risk factors aggressively to prevent ESRD and to improve donor
survival.
Lifetime risks of kidney donation: a medical decision analysis.
Patients who donate a kidney may be at greater risk of developing chronic kidney disease (CKD) as defined by a low glomerular filtration rate (GFR) of <60 ml/min/1.73 m2 or proteinuria which might lead to ESRD and high risk of death.
The aim of this study to estimate the potential loss of life as well as the added lifetime risk of ESRD in average-risk kidney donors.
Method.
No patients concluded in this study but the study relied on prior published analyses, targeted 40-year-old patients of both sexes and white/black race from the USA and to examine the risk of ESRD in a population of non-donors and donors they used Markov model (which figure out transition from the normal health state through other health states).
Result.
– The remaining life years lost from donation ranged between 0.532 years for white female and 0.884 years for black female donors.
– The percent loss of life varied from 1.20% for white female to 2.34% for black male (The per cent loss of life was highest in black male donors).
– The percent loss of total QALYs varied from 0.76% for white female to 1.51% for black male.
– The added lifetime cumulative risk of ESRD was 4.645% in black male which much higher than white female.
– More than 50% of all ESRD events in donors occurred 25 years or more after donation (but occurred earlier in black men).
– An overall percent loss of remaining life years of 1.39%, 0.72%, 1.9% and 1.74% for white male, white female, black male and black female, respectively.
-Younger patients lost more potential years of life and had potentially greater risks of ESRD given longer exposure to reduced kidney function but loss of life was greater in older compared with younger donors.
– Life expectancies were markedly reduced and lifetime risks of ESRD increased for smokers and obese cohorts and donors with DM.
Conclusion:
Live kidney donation may reduce life expectancy by 0.5–1 year in most donors. The development of ESRD in donors may not be the only measure of risk(there are many co-morbidities) as most of the predicted loss of life predates ESRD.
Still living kidney donation is the best modality for treating ESRD patients worldwide for the recipient , community and cost wise, so it is considered so important to follow up kidney donors and control the associated risk factors to decrease the risk of CKD and improving the total outcomes.
Level of evidence:3
To project the 15 years and lifetime cardiovascular mortality and ESKD risk in Kidney donors, this study was conducted. As it was increasingly reported, adverse outcomes, particularly cardiovascular mortality and risk of ESKD, related to kidney donation is gaining potential. Initially, the common believe was, kidney donation impart minor risk of CVD mortality and ESKD.
The followings are the main hypothesis to test:
1]The risk of CKD {and therefore ESKD} is higher secondary to renal mass reduction which will be culminating in a GFR below 60 ml/min.
2] those donors are prone to develop hypertension and DM later post donation which would potentiate the risk of deterioration entailed by the mentioned confounders.
3] The age-related inherent diminution of GFR is suspected to be precipitous and detrimental in kidney donors as their baseline GFR is subnormal in the first place.
Methods:
All patients with 15 years follow up after kidney donation compared to a controlled cohort. By using Markov medical decision analysis. 40-year-old life kidney donors of both sexes, black and white races.
Intervention is live donation nephrectomy.
Results:
This study showcased the risk of 1-5 % of ESKD kidney donors’ group.
Most events reported after 25 years of donation.
Male and black are at increased risk of adverse events.
Most of loss of life was linked to chronic kidney disease, not the ESKD.
life expectancy was reduced by 0.5 -1 year in comparison to non-donor control group.
smoking and obesity were risk factors for chronic kidney disease progression.
This study points up the importance of follow up the donors, closely addressing their risk factors and managing thereof.
It’s a retrospective study with level of evidence 3
. Please summarise this article in your own words
-The recent reports show that there is some increase in risk of end-stage
renal disease (ESRD) from donation and possibly an increase in cardiovascular
mortality.
-Patients who donate a kidney may be at greater risk of developing chronic
kidney disease , diabetes mellitus and hypertension.
– Donor with minor medical abnormalities, men and individuals
of black race had greater 15-year and lifetime risks of ESRD.
– objectives of this study were to estimate the potential loss of life as well as the added lifetime risk of ESRD in average- risk kidney donors.
– Although ESRD is associated with very high mortality rates, a significant per cent of the loss of life was associated with CKD not ESRD.
– The per cent of patients modelled to be alive at 20 years post nephrectomy for an average-age white male donor was only 0.2% lower than a non-donor .
– About 78% of the loss of all QALYs from donation was associated with CKD in white female, whereas the loss was 58% in black male.
– The baseline analysis showed that white males suffer greater added long-term ESRD risks from donation than would be anticipated.
– The loss of life from live kidney donation is projected to be
far less than smoking or mild obesity .
– The live partial liver donation may be less risky over the long run compared
with live kidney donation.
-Despite a higher postoperative mortality with partial live liver donation, kidney donation results in more loss of life when adding in the long-term impact.
– The life years lost from donation are greater than the life years gained from colorectal cancer screening in an average-risk person.
-The younger donors have greater added risks of ESRD and potential life years lost; however, the percentage loss of life was somewhat less compared with older cohorts.
-The effect of smoking and diabetes mellitus had large effects on overall survival and in lifetime risks of ESRD in donors and non-donors. The effects were less in obese donors compared with donors who were smoking or had diabetes mellitus. – Donors with diabetes mellitus were at very high added risks of ESRD
and death. A40-year-old white female with diabetes mellitus, who is otherwise well, has about the same added risk of ESRD and percentage loss of life years as a current ideal 40-year-old black male donor.
– Since donors eventually have a greater risk of entering into a more
advanced CKD state, this analysis may have underestimated the overall net loss of life years from nephrectomy.
-There is no data on family history of ESRD in the non-biological-related donors.
What is the level of evidence provided by this article?
Level 2
Renal donors have low post-operative mortality, but some studies have shown increased risk of developing GFR <60 ml/min or proteinuria, diabetes mellitus and hypertension and ESRD.
The study estimated the loss of life and risk of developing ESRD in living kidney donors of age 40 years over 15 years follow-up, by considering previously published studies and utilizing Markov model.
The outcomes measured included:
a) Remaining years of life and QALYs: Loss of 0.532-0.884 year from life (equivalent to 1.2-2.34% of remaining life). Risk of life-loss was higher in males and African-Americans. Loss of life is mostly due to CKD.
b) Lifetime cumulative ESRD incidence: 1-5%. Added risk of ESRD reduced 0.126-0.344 years from remaining life (maximum for black males and least for white females). More than 50% ESRD occurred more than 25 years post-donation.
Smoking, obesity, diabetes mellitus and biologically related organ donation were associated with increased lifetime risks of ESRD and loss of life. Risk associated with smoking and obesity in non-donors for decreased life and increased ESRD is more than the risk associated with donation in the donors.
The study showed that donation potentially reduced life by 1-2% in a 40 year old donor. Loss of life from living kidney donation is far less than that due to smoking or obesity. So, counselling for weight reduction and smoking cessation should be done and relevant interventions undertaken in this regard.
Limitations: The studies included had small numbers, short-term follow-up (<30 years) and lacked highly scrutinized controls. The study cohort was US donors, while the non-donor control population included international populations. The model did not include multiple stages of CKD. The donors included in the analysis were 40-year-old, while the data available is form a wide range of donors.
Level of evidence is level 2: Cohort study
Thank you Amit
The aim of this study is to demonstrate the living donor’s:
1- potential loss of life
2- loss of lifetime cumulative risk of ESRD
this study follows the Makov medical decision analysis design
following are the key assumptions for the model:
Results;
Differences in survival between the cohorts became apparent after 20 year
The per cent loss of total QALYs varied from 0.76% for white female to 1.51% for black male.
Live kidney donation was associated with an added risk of ESRD especially among those of male sex and black race.
The per cent loss of life attributed to ESRD in relation to total remaining years of life varied between 0.29% for white female and 0.88% for black male
Assuming the added proportion of time spent with isolated low GFR CKD had no increase in all-cause mortality rate
younger patients lost more potential years of life and had potentially greater risks of ESRD given longer exposure to reduced kidney function. However on a percentage basis, loss of life was greater in older compared with younger donors.
lifetime risks of ESRD increased for cohorts who were smokers or had diabetes mellitus. Obese patients were also at increased risk but lesser
Non-biological relationship to the recipient was associated with much lower loss of life years and risk of ESRD compared with those who were biologically related.
Conclusion
Asking donors whether they may be willing to give up between 0.5 and 1 year of life may be a better way to convey risk than giving them an estimate of their lifetime risk of ESRD.
In addition the study identifies the potential importance of following donors and treating risk factors aggressively to prevent ESRD and to improve donor survival
limitation of this study
The ability to predict lifetime outcomes from 15year follow-up in donors of all ages and medical conditions is a limitation.
Level of evidence (I am still confused either this is level 1 or 2
Summary:
Introduction:
30 000 live donor kidney transplant surgeries are performed ,Each year, the recipients’ benefits are improved life expectancy and quality of life compared with dialysis or deceased donor transplantation. The long-term risks are also p be undersized, especially in low-risk donors who are adequately screened.
Objectives
To estimate the potential loss of life and the added lifetime risk of ESRD in average-risk kidney donors.
Methods
Model Description:
The following are the critical assumptions for the model:
►► ESRD is increased in donors compared with non-donors.
►► ESRD in donors and non-donors will be associated with high mortality rates.
►► Donors and non-donors transition through a CKD state for at least one year before ESRD.
►► ESRD is increased in donors compared with non-donors. Therefore, we assumed there must have been an increase in the transition rate and CKD states.
►► Nephrectomy in donors will have a greater risk of falling below a GFR threshold of 60 mL/min/1.73 m2 than non-donors.
►► Cohorts are assumed to be non hypertension, diabetes mellitus, and proteinuria at donation. However, they are at risk of developing these conditions whether they donate, impacting patient survival and kidney function loss in both donors and non-donors. Given that some individuals may be at higher or lower risks of diabetes mellitus and proteinuria, smoke, or are obese, we examined these
in additional sensitivity analyses. Diabetes mellitus in non-donors would follow the same pattern (increasing rates with age) as in the general population, even though absolute rates might be lower (if initially screened to be negative).
►► CKD states will be associated with higher mortality rates than in the general population, but the magnitude of this effect was examined in additional sensitivity analyses.
►► Model transition rates from average to CKD states could be empirically derived (by working backward) to reproduce observed 15-year cumulative incidence rates for ESRD in donors and non-donors and can be used to project cumulative lifetime risks of ESRD subsequently. CKD in non-donors would follow the same pattern (increasing rates with age) as in the general population but at overall lower rates
The model was developed using TreeAge Pro 2015 (TreeAge Software, Williamstown, Massachusetts, USA). Ethics approval was not required because this is a theoretical model that uses published population data.
Patient involvement in study design:
The study design, development, and research question did not involve patient input, nor were outcomes informed by patient priorities
Target population
The base case cohorts were 40-year-old patients of both sexes and white/black race from the USA
Main outcome measures:
The health outcome of interest was remaining years of life (undiscounted). Since the quality of life is reduced in patients with ESRD and other related health states and these events are downstream, life years were scaled by quality measures and discounted at a 3% rate of time preference to calculate QALYs. Lifetime cumulative incidence
of ESRD was also calculated.
Intervention effects
Donors in the study underwent unilateral nephrectomy
Time horizon
The time horizon for remaining life years and QALYS was a lifetime
Analysis, design, and outcomes
All analyses compared outcomes of the same population of healthy potential donors and modeled the effects of all donated.
Non-donors were assumed to have 15-year cumulative ESRD risks of 0.067%, 0.045%, 0.21%, and 0.12% for white males, white females, black males, and black females, respectively. Donors were assumed to have 15-year cumulative ESRD risks of 0.34%, 0.15%, 0.96%, and 0.59% for white males, white females, black males, and black females, respectively.
Uncertainty and sensitivity analyses:
We assumed that many future risks that can impact life expectancy and ESRD, such as cancer, obesity, and smoking, were not influenced by the act of kidney donation
Results:
1- Overall, 0.532–0.884 remaining life years were lost from donating a kidney.
2-It was equivalent to 1.20%–2.34% of remaining life years (or 0.76%–1.51% remaining QALYs).
3-The risk was higher in male and black individuals.
The study showed that 1%–5% of average-age current live kidney donors might develop ESRD due to nephrectomy.
4- The added risk of ESRD resulted in a loss of only 0.126–0.344 remaining life years.
5-Most of the loss of life was predicted to be associated with chronic kidney
disease (CKD), not ESRD.
6-Most events occurred 25 or more years after donation. Reducing the risk of death associated with CKD had a modest overall effect on the percent loss of remaining life years (0.72%–1.9%) and QALYs (0.58%–1.33%).
7-Smoking and obesity reduced life expectancy and increased overall lifetime risks of ESRD in non-donors.
However, the percentage loss of remaining life years from a donation was not significantly different in those with or without these risk factors.
Conclusion:
Live kidney donation may reduce life expectancy by 0.5–1 year in most donors. The
development of ESRD in donors may not be the only measure of risk, as most of the predicted loss of life predates ESRD. The study identifies the potential importance of following donors and treating risk factors aggressively to prevent ESRD and improve donor survival.
Strength of study :
► The study projects the long-term risk of donating a kidney, including loss of life and the added risk of end-stage renal failure.
► These findings help quantify and communicate risk to potential donors and convey the importance of lifelong follow-up in actual donors.
► The study uses evidence of over 15 years of follow-up in actual live kidney donors and healthy controls.
Limitation :
► The ability to predict lifetime outcomes from 15- year follow-up in donors of all ages and medical conditions
Level 2
Living donor kidney transplantation provides recipients with better quality of life and better life expectancy with mild risk to the donors and low postoperative mortality.
Long term risks are presumed to be low.
However, recently, studies suggested increased risk of ESRD and cardiovascular mortality after donation.
Kidney donors are at higher risk of CKD and proteinuria and may develop DM and HTN despite screening at time of donation leading to accelerated loss of kidney functions.
The impact of donation on remaining life years and remaining quality adjusted life years (QALY) is important to be considered with other behavioral and environmental exposures.
The study aimed to estimate the effect of donation on potential loss of life and increased lifetime risk of ESRD in average risk donors.
It depends on previously published analyses focused on risk of ESRD post donation without patient recruitment.
It showed that donation decrease potential life expectancy by 1-2%
Pre-dialysis mortality accounted for most of loss of life and decreased QALY so suggesting that progression from CKD to ESRD occur over years.
The association between donation and increased risk of death is not well determined as studies included have small numbers, lack healthy controls with short follow up duration.
Mortality risk in average age white donor is 0.2% lower than non donors
Modest decrease in percent of total life years and QALY after developing CKD.
White male donors have greater added long-term ESRD risks than expected, may be due to longer life expectancy or because white males may have more permissible criteria for donation.
The loss of life due to kidney donation is projected to be less than that due to smoking and obesity.
Younger donors have more added risks of ESRD and potential life years lost.
Smoking and DM lave large effect on overall survival and lifetime risk of ESRD in donors and nondonors.
The study suggest that weight loss and cessation of smoking are important for donors and nondonors.
Donor with non-biological relation have lower risks than related donors.
The study determined the potential importance of long-term follow up of donors, adequate treatment of risk factors and improving lifestyle to prevent ESRD and improve donor survival .
Limitations:
Compared rate of ESRD over 15 years in actual donors with theoretically matched cohort
Used historic mortality and disease incidence rate to make future projections.
It analyzed US donors with international population of non donors so can’t be generalized to donors from other countries with different ESRD rates.
Many variables and transition rates were included
Didn’t include multiple stages of CKD
Used cohort of 40 year old individuals for analysis, however donor have wide range of ages.
No data about family history of ESRD in nonbiological related donors.
Level 1 (Meta-analysis study)
IV. Lifetime risks of kidney donation: a medical decision analysis
Please summarise this article in your own words
This study aimed to estimate the long-term of death & ESRD in kidney donors.
Markov medical decision model was used to analyse ESRD in non-donors & donors.
The target population were 40-year-old patients of from the USA(male/female, white/black race); 40 year is the mean age of live donors & for whom recent estimates of 15-year risks of ESRD in non-donors & donors are available; the study relied on published analyses, not on recruiting participants.
The main outcome measured were:
– The potential remaining life years lost
– Quality-adjusted life years (QALYs)
– Added lifetime risk of ESRD from donation..
The intervention effect of the study is unilateral nephrectomy done in donors.
Secondary outcomes:
– The loss of life attributed to ESRD.
Results
-The remaining life years lost from donation: 0.532 (white female) to 0.884 years (black female). This was equivalent to 1.20%–2.34% of remaining life years (or 0.76%–1.51% remaining QALYs). The risk was higher in male & black donors.
-The added lifetime cumulative risk of ESRD: 1.135% (white female) to 4.645% (black male); this means 1 added ESRD event for every 88 white female or 1 added ESRD event for every 22 black male donors.
-The % loss of life due to ESRD in relation to total remaining years of life: 0.29% (white female) to 0.88% (black male). Most of the loss of life was associated with CKD not ESRD. Most events occurred 25 or more years after donation.
-Smoking & obesity reduced life expectancy & increased lifetime risks of ESRD in non-donors; however the % loss of remaining life years from donation didn’t differ in those with or without these risk factors.
Discussion
Donation potentially shortens life in average-age donors by about 1%–2%.
Short-term studies (<20 years) might not detect adverse effect on survival.
ESRD is associated with very high mortality rates; however a significant % of the loss of life was associated with CKD not ESRD.
Risk factors associated with higher rates of death & ESRD (smoking, obesity & biological relationship) were also explored.
From studies with small number of patients it was unclear whether there is a significant risk of death from donation; an important mortality signal could have easily been missed.
In this study, the % of patients modeled to be alive at 20 years post nephrectomy for an average-age white male donor was only 0.2% lower than a non-donor. Greater differences were seen later (more than 30 years) when the cumulative effects of CKD were more evident. The lower GFR CKD from donating a kidney may well be different from the CKD due to proteinuria or DM; however, risks associated with CKD explored in the model showed only a modest reduction in the % of total life years & QALYs lost.
The model included probability that some donors will develop DM, HTN & proteinuria at a later date; these would have impact on health (overall survival & progression to ESRD) as they do in the general population.
The white males have greater added long-term ESRD risks from donation than would be anticipated.
The loss of life from live kidney donation is far less than smoking or mild obesity.
Smoking & DM diabetes mellitus had large effects on overall survival & in lifetime risks of ESRD in donors and non-donors; the effects were less with obese donors compared with smoking or DM.
A 40-year-old white female with DM (otherwise well) , has the same added risk of ESRD & % loss of life years as a current ideal 40-year-old black male donor.
Limitations
Historic mortality & disease incidence rates were used to make accurate future lifetime projections.
US donors were included (the non-donor controls were both US and international); so, the results may not be applicable to live kidney donors from other countries where population ESRD rates are much lower.
================================
What is the level of evidence provided by this article?
Level II
The aim o the study ;
This study estimated the potential loss of life and the lifetime cumulative risk of end-stage renal disease (ESRD) from live kidney donation.
Methods;
A USA-based Markov model was used to examine the risk of ESRD in a population of non-donors and donors.
Patient involvement in study design;
There was no patient recruitment or participation in this study but rather the study relied on prior published analyses.
Target population;
The base case cohorts were 40-year-old patients of both sexes and white/black race from the USA. This is the mean age of live donors (median age 38) and for whom there are recent published estimates of 15-year cumulative risks of ESRD in non-donors and donors.
Main outcome measures;
Potential remaining life years lost, quality-adjusted life years (QALYs) lost and added lifetime cumulative risk of ESRD from donation.
Intervention effects;
Donors in the study underwent unilateral nephrectomy. It is assumed that the nephrectomy results in a loss of GFR, and this loss of function would increase the probability of transitioning from a normal (GFR ≥60 mL/min/1.73 m2) kidney function heath state to CKD.
Analysis and design
1-All analyses compared outcomes of the same population of healthy potential donors and modelled the effects if all donated.
2- In addition we examined the loss of life attributed to ESRD by eliminating the ESRD health state in both donors and non-donors and assumed all remained in CKD until death.
3-In the base case analysis, age, sex and black/white race annual transition rates for proteinuria, diabetes mellitus and hypertension were empirically derived from population studies assuming that donors were initially disease-free but could subsequently develop these conditions at rates seen in the general population.
The results ;
1-Live kidney donation may reduce life expectancy by 0.5–1 year in most donors.
2-The development of ESRD in donors may not be the only measure of risk as most of the predicted loss of life predates ESRD.
3-The study identifies the potential importance of following donors and treating risk factors aggressively to prevent ESRD and to improve donor survival .
Conclusion;
1-The analysis shows that younger donors have greater added risks of ESRD and potential life years lost; however, the percentage loss of life was somewhat less compared with older cohorts.
2-The effect of smoking and diabetes mellitus had large effects on overall survival and in lifetime risks of ESRD in donors and non-donors. The effects were less in obese donors compared with donors who were smoking or had diabetes mellitus.
3-The incremental effects with donation in subjects with and without obesity and smoking varied slightly by sex and race but overall were not very different .
4-The analysis suggests that counseling and interventions to reduce weight and smoking cessation are more important to both donor and non-donor and less of an argument to deny donation.
5- Having a non-biological relationship to the recipient was associated with lower risks; however, the majority of donors are related.
6- Donors with diabetes mellitus were at very high added risks of ESRD and death. It is interesting to point out that a 40-year-old white female with diabetes mellitus, who is otherwise well, has about the same added risk of ESRD and percentage loss of life years as a current ideal 40-year-old black male donor.
What is the level of evidence provided by this article?
Level III
Retrospective cohort study .
SUMMARY:
The growth in the number of successful kidney transplantation has brought a remarkable improvement in the quality of life of the recipient but the same cannot be said of the donor. Furthermore, some studies has shown an increase in cardiovascular disease, CKD, and ESRD among donor with long term follow up.
The objective of the study:
Methods:
Results:
Conclusion
The study showed that kidney donation do shorten life by 1%- 2%, though short term study (<20 years) with appropriate control may not show any adverse outcome on survival. It is of note that, the overall loss of life in the entire population is average, but the impact on the younger donor are more compared to those that donate kidney at old age,
The level of evidence is 2
This study was based on risk prediction model to assess the lifetime risks of kidney donation. The authors used the Markov medical decision model to come up with the incidence of :
A USA-based Markov model was used to examine the risk of ESRD in both donors and non-donors.
The authors used a previously published model and updated it to include the population under study and ESRD vital statistics and current cumulative risks of DM, CKD and ESRD from published sources. So, there was no actual patient involvement or recruitment for this study. The study relied on previously published data.
The case cohorts chosen were 40 year old male and female Caucasian and African-American subjects. The primary outcomes were remaining years of life, QALYs lost and the cumulative incidence of developing ESRD. The study looked at intervention effects in the donors. The intervention in donors was a unilateral nephrectomy and the effects was what was looked at which was the loss of GFR and progression to CKD – GFR < 60 mls/min. The patients were followed for life apart from the outcome for ESRD which was stopped at 90 years. The cohort was healthy potential donors and they were analyzed for outcomes assuming they had all donated. Transition rates from normal GFR to CKD were derived from previously published studies. The rates were multiple by an empirically derived coefficient that was lower in the non-donors than the donors to reproduce the 15 year ESRD risking non-donors and donors. The age, gender and race annual transition to develop proteinuria, DM and HTN were also derived from previously published studies.
The projected survival was similar between donors and donors up to 20 years after which it was higher in the non-donors. The remaining life-years lost after donation was highest in African American males and lowest in the Caucasian females. The percent loss of QALYs was also highest in African American males and lowest in Caucasian females.The lifetime cumulative risk of ESRD was 1.135% in Caucasian females and 4.645% in African males. The precent loss of life attributed to ESRD in relation to total remain years of life varied between 0.29% for White females and 0.88% for African males.
In the sub-analysis, the younger population of patients had more life years lost and had a higher risk of developing ESKD – because they would live longer with a unilateral kidney. Donors with DM suffered the the greatest loss of life years and had the highest risk of developing ESRD.
If the donors were not biologically related to the recipient, they would have a lower incidence of lost life years and progression to ESRD.
A very important point of this study is that for up to 20 years there may be no difference between donor and non-donors. The differences become apparent after 20 years. Future studies need longer follow up periods of more than 20 years. A significant proportion of mortality was due to CKD and not ESRD as was expected. The presence of CKD also accounted for most of the reduction in QALYs. Therefore, it is important to identify risk factors that will lower GFR to develop CKD like DM, HTN, proteinuria and treat them appropriately. The risk of developing ESRD increased in the White males after 25030 years of follow up possibly due to longer life expectancy of the white males.
The study had several limitations:
Level of evidence
The level of evidence is level II. This is a case cohort study followed up for 15 years. The outcomes were identified and analyzed for the risk factors based on previously published data
Please summarise this article in your own words
Study objective : estimation of potential loss of life and the lifetime cumulative risk of ESRD in living donors in US in comparison to international cohort.
Target population : 40 year-old ( the mean age of kidney donors) of both sexes with different races in the USA , compared to an international donors cohort from different ages and races. measuring an estimate on 15-year cumulative risk of ESRD in non donors and donors, knowing the overall effect of donation in remaining life years and quality adjusted life years (QALYs)
Results:
The differences between donors and non donors appear in 20 years post donation, life years lost from donation and QALYs were more pronounced in black males.
more than 50% of all ESRD events occurs 25 years or more after donation.and was more in black males.
Donors spent 50-85 %more time with an isolated low GFR.
Younger lost more potential years of life and greater risk of ESRD, but loss of life was greater in older donors.
The study explore risk factors associated with increased risk of death an ESRD, ie; obesity, smoking, biological relationship, hypertension and DM, so intervention could help in preventing ESRD and improve survival.
Donation shortens life in average age-age donors by 1-2%.
Limitations:
Analyse US donors compared ti international non-donors.
Not includes all stages of CKD and proteinurea levels.
Only 40 year old donors were compared to all ages in the cohort.
Conclusion:
All donors should be evaluated and followed after donotaion and the risk factors identified and treated ( obesity , smoking , HTN, etc ), as these modifiable risk factors could decrease the risk of ESRD development.
The donation decrease life expectancy by 0,5 – 1 year.
What is the level of evidence provided by this article?
Level of evidence is IIc – outcome research (cohort)
My reply is related to the level of evidence this article provides. Your answers have varied from level 2 to level 3.
It is a simplified approach when it is not an RCT:
Stepwise approach:
Q 1: Is it an observational study or an interventional study.
A 1: It is an observational study. Donor nephrectomy is an operation been performed in study group but it is not an intervention from the point of view of research.
Q2: Is it a longitudinal study or a cross sectional study?
A 2: It is a longitudinal study.
Q3: We know that it is a longitudinal study. Is it a cohort study or case control study?
A 3: Case-control studies are always retrospective, we find out the end-point (ESRD, death, DM or HT in donors) and one looks back for underlying factors. While in cohort studies ( that is either prospective or retrospective) we start with risk factors and follow these patients to look for the end-point (primary, co-primary and secondary).
Conclusion: This is an observational longitudinal cohort study with population data as controls.
Therefore, this article provides level 2 evidence.
Apologies, this was deleted as it was repetition of my reply.
The provided article s a metanalysis with level of evidence 1
The study evaluated the potential remaining life years lost, quality-adjusted life years lost and added lifetime cumulative risk of ESRD from donation.
A USA-based Markov model was used to examine the risk of ESRD in a population of non-donors and donors. The base case cohorts were 40-year-old patients of both sexes and white/black race from the USA. This is the mean age of live donors (median age 38) and for whom there are recent published estimates of 15-year cumulative risks of ESRD in non-donors and donors
The study design, development and research question did not involve patient input, nor were outcomes informed by patient priorities. There was no patient recruitment or participation in this study but rather the study relied on prior published analyses.
Results
– The projected survival of average-age donors and non-donors appears to show differences in survival between the cohorts after 20 years or more after donation.
– Life years lost from donation is 0.532 years for white female and 0.884 years for black female donors.
– Loss of life percent is 1.20% for white female and 2.34% for black male.
– The per cent loss of total QALYs is 0.76% for white female and 1.51% for black male.
– The added lifetime cumulative risk of ESRD varied from 1.135% in white female to 4.645% in black male
– The added ESRD events tended to occur earlier in black male compared with white male.
– In a subgroup analyses younger patients lost more potential years of life and had potentially greater risks of ESRD given longer exposure to reduced kidney function.
– Non-biological relationship to the recipient was associated with much lower loss of life years and risk of ESRD compared with those who were biologically related.
The study estimates potential loss of life, and lifetime cumulative risk of ESKD, as a result of live kidney donation.
Methods.
A USA -based Markov models was used to examine the risk of ESKD in donors and non-donors in general population .
Key assumptions of the models:
Previous published study was updated to include current general population and ESKD vital statistics, and cumulative risk for DM, CKD, ESKD.
Target population;
Base case cohort were 40 years old, from both sexes, white and black, from USA.
The primary outcome noted that , the net difference in remaining life years, QALYs, and development of ESKD .
Results;
Differences in survival between cohort becomes apparent after 20 years post donation, remaining life years lost from donation ranged from 0.532 years for white female, and 0.883 years for black female donors.
Percent of life loss was highest in black male donors.
Percent loss of life varied from 1.20 % for white female to 2.34% for black male.
Percent loss of total QALYs varied from o.76% from white female, to 1,51% for black male.
Living kidney donors was associated with an added risk of ESKD, especially among those of male sex for black male, the lifetime cumulative rsik of ESKD varied from 1.135% in white female to 4.4645% in black male, this translated to one added ESKD event for every 88 white female or one added ESKD event for every 22 black male donors.
> 50% of all ESKD events in donors occurred at 25 years or more post donation.
The added ESKD risk events tends to occur earlier in black male compared to white male .
percent loss of life to ESKD varied between 0.29% for white female and 0.88 % for black male.
Younger patients lost more potential years of life and potentially have greater risk of ESKD given longer exposure to reduce kidney function.
Loss of life was greater in older compared with younger donors.
Life expectancy markedly reduced and lifetime risk of ESKD increased for cohort whio were smoker or diabetics or obese.
DM donors greatest loss of life years and increase risk of ESKD.
Non-biological relationship to recipients associated with lower loss of lifetime risk of ESKD, compared with biologically related.
Discussion;
Awareness by long-term risks associated with kidney donation, is vital to potential donors, this analysis show that short term studies (<20 years), even with appropriate normal control are not likely to detect adverse effect on survival.
Although ESKD is associated with very high mortality rate , a significant percent of loss of life was associated with CKD not ESKD.
Study also explore risk factors associated with higher rate of death and ESKD, such as smoking, obesity , and bilogical relationship to the recipients.
Lower GFR as a result of donation , well different from CKD that associated with proteinuria, DM, , and the lower mortality rate associated CKD as a result of donation from CKD from general population.
The lost rate of life per time post donation , increases may be because of some donors develop DM ,HTN, proteinuria post donation.
Level of evidence ((II)).
Thank You, why level 2?
The objectives; to estimate the potential loss of life as well as the added lifetime risk of ESRD in average-risk kidney donors.
Design; A USA-based Markov model was used to examine the risk of ESRD in a population of non-donors and donors.
The study relied on prior published analyses.
Target population; 40-year-old patients of both sexes and white/black race from the USA.
Intervention Live donor nephrectomy.
Main outcome and measures Potential remaining life years lost, quality-adjusted life years (QALYs) lost and added lifetime cumulative risk of ESRD from donation.
Time horizon The time horizon for remaining life years and QALYS was lifetime. However, for ESRD, the cumulative incidencewas truncated at age 90 in keeping with other studies
Analysis; All analyses compared outcomes of the same population of healthy potential donors and modelled the effects if all donated.
Cohort assumed that donors were initially disease-free but could subsequently develop these conditions at rates seen in the general population.
Results:
Differences in survival between the cohorts became apparent after 20 years or more after donation.
The remaining life years lost from donation ranged between 0.532–0.884
This was equivalent to 1.20%–2.34% of remaining life years (or 0.76%–1.51% remaining QALYs).
The risk was higher in male and black individuals.
The study showed that 1%–5% of average-age current live kidney donors might develop ESRD as a result of nephrectomy.
The added risk of ESRD resulted in a loss of only 0.126–0.344 remaining life years.
Most of the loss of life was predicted to be associated with chronic kidney disease (CKD) not ESRD.
Most events occurred 25 or more years after donation.
Death during the CKD health state accounted for most of the projected increase in mortality and reduction in QALYs. Intuitively this makes some sense given that the transition from CKD to ESRD can be over many years and that progressive kidney disease is associated with graded increases in mortality
Despite differences in the absolute rates of ESRD in both donors and non-donors, the absolute and percent loss of life years and QALYs from donation were only modestly lower compared with the base case analysis.
Smoking and obesity reduced life expectancy and increased overall lifetime risks of ESRD in non-donors.
However the percentage loss of remaining life years from donation was not very different in those with or without these risk factors.
Conclusion Live kidney donation may reduce life expectancy by 0.5–1 year in most donors. The development of ESRD in donors may not be the only measure of risk as most of the predicted loss of life predates ESRD. The study identifies the potential importance of following donors and treating risk factors aggressively to prevent ESRD and to improve donor survival.
the study based on published analysis, systemic review level 1
-Introduction
Mostly the risk for donors is small particularly if they are of low risk and are followed regularly.
Recent studies highlighted that kidney donors are at high risk of development of CKD ,ESRD and cardiovascular complications others can develop HTN ,DM on long term bases.
A study assessed the 15 years and life time risk of experiencing ESRD in potential non donors and revealed that candidates with minor medical comorbidities , male , and those of black race are subjected to higher risk.
This study aims at evaluating the possible death and the added lifetime risk of ESRD in average-risk kidney donors.
Methodology
Markov model was used to evaluate the risk of ESRD in non-donors and donors.
This model supposed that;
· ESRD will be more associated with donors than non donors and that both candidates with ESRD will have high mortality rate.
· Both candidates will go through CKD before reaching ESRD
· Nephrectomy will be associated with low GFR threshold of 60mL/min/1.73m2 compared with non-donors.
· Candidates are supposed to be disease free and can be at high risk of developing DM ,HTN , or proteinuria later on if donated or if didnot donate along with their impact on survival and renal function
· CKD cases have high mortality risks
· Transition rates from normal to CKD states
Can be derived to reproduce observed 15-year cumulative incidence rates for ESRD in donors and non-donors .
The study included data published before on the estimates of 15-year cumulative risks of ESRD in non-donors and donors for 40 y old candidates of both sexes and races.
QALYs were calculated and lifetime cumulative incidence of ESRD was also calculated.
Results
Survival variation between the cohorts was noticed after 20 years or more after donation.
The per cent loss of life was highest in black male donors.
The % loss of life ranged from 1.20% for white
female to 2.34% for black male. The % loss of total
QALYs varied from 0.76% for white female to 1.51% for black male.
The added lifetime cumulative risk of ESRD
Ranged from 1.135% in white female to 4.645% in black male.
Most ESRD events in donors happened 25 years or more
after donation.
Donors experienced 50%–85%more time with an isolated low GFR CKD compared with non-donors.
Overall % loss of remaining life years of 1.39%, 0.72%, 1.9% and 1.74% for white male, white female, black male and black female, respectively.
Younger candidates were subjected to more loss of years of life and higher liability of ESRD development due to longer time of exposure to low GFR , on the other hand on % bases loss of life was greater in older candidates.
ESRD and less life expectancy were associated with smoking, obesity and DM mean while obese smoker donors had little less risk than non obese non smoker donors.
Diabetic donors had the greatest loss of life years and increased risk of ESRD.
Life loss and ESRD were higher in biologically related donors to recipients.
Discussion
This study revealed that donation can shorten life in average age donors by 1%–2% also short-term studies even with suitable controls are unable to detect an adverse effect on survival. CKD not ESRD was associated with significant % of life loss.
Risk factors associated with increased risk of ESRD and death as smoking, obesity and DM were assessed.
Meanwhile it is not clear whether donation has a significant impact on death risk or not.
The possible % to be alive after 20 y of donation for average aged white donor is 0.2% less than matched non donor candidate.
CKD occurring due to low GFR post donation need to be differentiated from CKD associated with proteinuria and DM .
Some studies noticed that DM and HTN can occur post donation and lead to ESRD.
The model overestimated the lifetime ESRD predictions in non-donors .
White males had long-term ESRD higher risks from donation than would be supposed could be due to longer life expectancy .
Death due to donation is much less than death due to smoking or obesity
Live partial liver donation seems to be less risky over time than live renal donation although the former has higher perioperative mortality risk .
Smoking and diabetes mellitus had great impact on overall survival and in lifetime risks of ESRD
in donors and non-donors. The effects were less in obese donors compared with donors who were smoking or had diabetes mellitus.
Smoking cessation and wight loss are important to donors and non donors and less debatable topic for forbidding donation.
A 40-year-old white female with diabetes mellitus, who is otherwise well, has the same added risk of ESRD and percentage loss of life years as a current ideal 40-year-old black male donor.
Old mortality and disease incidence rates were used to make future lifetime projections is a significant
Limitation as ESRD and DM risk are increasing.
There were many variables and transitions included in the model but CKD stages were not included.
The ability to predict lifetime prognosis from 15-
year follow-up of donors of all ages and medical
conditions is a limitation.
Informing the donors about the possibility of giving up between 0.5 and 1year of life may be a better way to explain the risk than giving them an
estimate of their lifetime risk of ESRD
Long term follow up of donors is essential to avoid risks .
-level of evidence is III
Lifetime risks of kidney donation: a medical decision analysis
Summary of the Article
CKD is associated with multiple comorbidities and the noticed increased in mortality related to CKD is an important driver of life years lost.
In this study, a USA-based Markov model was used to examine the risk of ESRD in a population of non-donors and donors. There was no patient recruitment or participation in this study but rather the study relied on prior published analyses.
In this study, a sensitivity analysis was assumed that the added time spent in isolated CKD (no proteinuria nor diabetes mellitus) in donors compared with non-donors was not associated with an increase in mortality. In other sensitivity analyses age at donation, smoking status, higher body mass index, new-onset diabetes mellitus and biological relationship to recipient were explored.
The targeted population were 40-year-old patients of both sexes and white/black race from the USA.The time horizon for remaining life years and quality-adjusted life years (QALYS) was lifetime.
Study outcome
1. Differences in survival between the cohorts became apparent after 20 years or more after donation.
2. More than 50% of all ESRD events in donors occurred 25 years or more after donation.
3. The added lifetime cumulative risk of ESRD varied from 1.135% in white female to 4.645% in black male.
4. The per cent loss of life attributed to ESRD in relation to total remaining years of life varied between 0.29% for white female and 0.88% for black male.
5. On a percentage basis, loss of life was greater in older compared with younger donors. life was greater in older compared with younger donors.
6. Life expectancies were markedly reduced and lifetime risks of ESRD increased for cohorts who were smokers or had diabetes mellitus.
7. Surprisingly the absolute loss of life years was slightly less in donors who were obese or smoked compared with donors without these conditions.
8. Donors with diabetes mellitus suffered the greatest loss of life years and increased risk of ESRD.
9. The effect of smoking and diabetes mellitus had large effects on overall survival and in lifetime risks of ESRD in donors and non-donors.
10.Live kidney donation is found to be associated with less peri-operative death rate(0.31death/1000 operations in comparison to live liver donation(1.7/1000), but kidney donation results in more loss of life when adding in the long-term impact.
11.The non-biological relationship to the recipient was associated with lower risk.
Limitations of the study
1. Life expectancy and the cumulative incidences of diabetes mellitus and ESRD are increasing.
2. Using historic mortality and disease incidence rates to make accurate future lifetime projections is a significant limitation.
3. The study was an analysis of US donors, whereas the non-donor control population included US and international populations. The results may not be generalized to live kidney donors from other countries where population ESRD rates are much lower.
4. The model did not include multiple stages of CKD.
5. There was no data on family history of ESRD in the non-biological-related donors.
6. There are many variables and transition rates included in this model and addressing uncertainty in each.
7. Combinations of variables would require a much longer paper.
8. The key uncertainties explored were the cumulative risks of developing ESRD and the increased mortality associated with CKD states..
Strength of the study
1. Asking donors whether they may be willing to give up between 0.5 and 1year of life may be a better way to convey risk than giving them an estimate of their lifetime risk of ESRD.
2. The study identifies the potential importance of following donors and treating risk factors aggressively to prevent ESRD and to improve donor survival.
What is the level of evidence provided by this article?
This is a retrospective study .
Level of evidence is grade III.
Objective:
According to the findings of this research, live kidney donation may increase both the risk of death and the cumulative risk of developing the end-stage renal disease (ESRD) over a lifetime.
Design: a Markov model for clinical decision making.
Participants were 40-year-old live kidney donors of either black or white race who were of either gender.
Intervention Nephrectomy performed on a live donor.
The main outcome and evaluating criteria are Loss of potential remaining life years, quality-adjusted life years (QALYs), and an increase in the lifetime cumulative risk of end-stage renal disease (ESRD) due to donation.
Results:
Overall, kidney donation resulted in a loss of between 0.532 and 0.884 more years of life. This was comparable to 0.76%–1.51% of the remaining quality-adjusted life years (or 1.20%–2.34% of the remaining life years). Males and those of African descent have a significantly increased risk. According to the findings of the research, the incidence of end-stage renal disease (ESRD) after nephrectomy ranges from 1% to 5% among current living kidney donors of average age. The increased likelihood of developing ESRD was associated with a reduction of just 0.126–0.344 more life years lost. It was anticipated that most deaths would be caused by chronic kidney disease (CKD), and not the end-stage renal disease (ESRD). The majority of activities took place at least 25 years following the contribution. The reduction of the increased risk of mortality associated with CKD had a small overall impact on the percentage of remaining life years (0.72–1.9%) and QALYs (0.58–1.33%) that were lost. In non-donors, the effects of smoking and obesity were a decrease in life expectancy and an increase in the total lifetime risk of ESRD. However, there was not a significant difference in the proportion of remaining life years lost due to donation between individuals who had these risk factors and those who did not.
Conclusion In most people, donating a kidney while they are still alive may cut their life expectancy by half a year to one year. It is possible that the development of ESRD in donors is not the sole measure of risk, given that the majority of the anticipated loss of life occurs prior to the formation of ESRD. The research highlights the potential significance of monitoring donors and addressing risk factors in a proactive manner in order to reduce the incidence of end-stage renal disease (ESRD) and increase donor survival.
Retrospective cohort study, level 2
Thank you for your reply. See my comment above.
Please summarise this article in your own words
-This study estimated the potential loss of life and the lifetime cumulative risk of (ESRD) from live kidney donation.
-Nearly 30 000 live donor kidney transplant surgeries are performed throughout the world each year.
-The risks to the donors are generally felt to be small to modest, with a low postoperative mortality (approximately 3.1 deaths per 10 000 operations).
-The long-term risks are also presumed to be small especially in low-risk donors who are adequately screened.
-Recent reports however show that there is some increase in risk of (ESRD) from donation and possibly an increase in cardiovascular
mortality.
-Patients who donate a kidney may be at greater risk of developing (CKD) as defined by a low (GFR) of <60 mL/ min/1.73 m2 or proteinuria and some donors will develop diabetes mellitus and may be at higher risk of developing hypertension.
-This study were to estimate the potential loss of life as well as the added lifetime risk of ESRD in aver- age-risk kidney donors.
Methods
-The risk of ESRD in a population of non-donors and donors.
-The transition from the normal health state through other health states.
The following are the key assumptions for the model:
– ESRD rates are increased in donors compared with non-donors.
– ESRD in both donors and non-donors will be associateed with high mortality rates.
– Donor and non-donors transition through a CKD state for at least 1 year before developing ESRD.
-ESRD rates are increased in donors compared with non-donors, we assumed there must have been an increase in the rate of transition to and time spent in CKD states.
-Nephrectomy in donors will quantitatively reduce overall patient kidney function.
– Given that kidney function declines over time in most individuals, donors will have a greater risk of falling below a GFR threshold of 60 mL/min/1.73 m2 compared with non-donors.
-Cohorts are assumed to be free of hypertension, diabetes mellitus and proteinuria at donation, and risk of developing these conditions whether they donate or not, and these will impact patient survival and loss of kidney function in both donors and non-donors.
-Given that some individuals may be at higher or lower risks of diabetes mellitus and proteinuria, smoke or are obese, we examined these in additional sensitivity analyses.
-Diabetes mellitus in non-donors would follow the same pattern (increasing rates with age) as in the general population even though absolute rates might be lower (if initially screened to be negative).
– CKD states will be associated with higher mortality rates as in the general population, but the magnitude of this effect was examined in additional sensitivity analyses.
– Model transition rates from normal to CKD states could be empirically derived (by working backwards) to reproduce observed 15-year cumulative incidence rates for ESRD in donors and non-donors and can be used to subsequently project lifetime cumulative risks of ESRD.
-CKD in non-donors would follow the samepattern (increasing rates with age) as in the general population but at overall lower rates.
Target population
-The base case cohorts were 40-year-old patients of both sexes and white/black race from the USA.
-This is the mean age of live donors (median age 38) and for whom
there are recent published estimates of 15-year cumulative risks of ESRD in non-donors and donors.
Main outcome measures
-The health outcome of interest was remaining years of
life (undiscounted).
-Since quality of life is reduced in patients with ESRD and other related health states, and that these events are downstream, life years were scaled by
measures of quality and discounted at a 3% rate of time preference to calculate QALYs.
-Lifetime cumulative incidence of ESRD was also calculated.
Uncertainty and sensitivity analyses
-The lifetime estimates of ESRD were found to be higher in non-donors than published estimates, in part since this model incorporated the possibility that some participants could develop diabetes mellitus and proteinuria.
– Ideal non-donors were assigned lower incidence rates of diabetes mellitus, proteinuria and rates of transition to CKD to match projected lifetime ESRD risks rather than calibrating to 15-year ESRD risks.
-Non-donors were assumed to have lifetime cumulative ESRD risks of 0.43% (95% CI 0.19 to 0.58), 0.29% (95% CI 0.13 to 0.47), 1.00% (95% CI, 0.49 to 1.37) and 0.85% (95% CI, 0.37 to 1.35) for white male, white female, black male and black female, respectively.
-The increase in mortality associated withCKD is an important driver of life years lost, in a sensitivity analysis we assumed that the added time spent in isolated CKD (no proteinuria nor diabetes mellitus) in donors compared with non-donors was not associated with an increase in mortality.
Results
This was equivalent to 1.20%–2.34% of remaining life years .
-The risk was higher in male and black individuals.
-The study showed that 1%–5% of average-age current live kidney donors might develop ESRD as a result of nephrectomy.
-The added risk of ESRD resulted in a loss of only 0.126–0.344 remaining life years.
-Most of the loss of life was predicted to be associated with (CKD) not ESRD.
-Most events occurred 25 or more years after donation.
– Reducing the increased risk of death associated with CKD had a modest overall effect on the per cent loss of remaining life years (0.72%–1.9%) and QALYs (0.58%–1.33%).
– Smoking and obesity reduced life expectancy and increased overall lifetime risks of ESRD in non-donors.
– However the percentage loss of remaining life years from donation was not very different in those with or without these risk factors.
strengths and limitations of this study
– The study projects the long-term risk of donating a
kidney, including loss of life and the added risk of ESRD.
– These findings help quantify and communicate risk to potential donors and convey the importance of lifelong follow-up in actual donors.
– The study uses evidence of over 15 years of follow up in actual live kidney donors and healthy controls.
– The ability to predict lifetime outcomes from 15 year follow-up in donors of all ages and medical conditions is a limitation.
Conclusion
– Live kidney donation may reduce life expectancy by 0.5–1 year in most donors.
–The development of ESRD in donors may not be the only measure of risk as most of the predicted loss of life predates ESRD.
-The study identifies the potential importance of following donors and treating risk factors aggressively to prevent ESRD and to improve donor survival.
What is the level of evidence provided by this article?
The level of evidence 2
Thank you for your reply. See my comment above.
Please summarise this article in your own words
Kidney donation improves quality of life of recipient but may be associated with some risks. There can be perioperative morbidity and risk of death ( 3.1 @10000 donations). There can also be increased risk of Cardiovascular problems and ESRD.
The objective of this study was to assess the potential loss of life and risk of ESRD post kidney donation.
The study used Marko Medical decision analysis . 40 patients of both sex underwent donor Nephrectomy.
Results
The study found that there can be some loss of life years between 0.5-0.9 years ( 0.7-1.7 QALY).
The risk was higher in male and Blacks.
The risk of loss of life was associated with CKD and not ESRD.
Majority events happened 25 years post donation.
Smoking and obesity was found to be associated with decreased life expectancy and increased risk of ESRD.
Conclusion
Living kidney donation can decrease life expectancy by 0.5-1 years.
There is risk of ESRD post donation.
It is important to follow donors and treat risk factors to prevent ESRD to improve donor longevity.
What is the level of evidence provided by this article?
Cohort study
Level 11
Thank you for your reply. See my comment above.