Fibromuscular dysplasia (FMD) accounts for about 2.0–6.6% of kidney donors .It is is manifested by dissection, aneurysm and tortuosity of many vascular beds such as the renal, carotid, visceral, external iliac arteries and even the coronary arteries .This study compares the outcomes of HTN, CVD, proteinuria & GFR decline in donors with FMD versus donors without FMD.8922 kidney donors were being recruited and followed up for 15.5 6 8.9 years.
RESULTS:FMD do not increase the risk of hypertension ,CVD or GFR decline in donors but patient have to be thoroughly investigated for extra renal involvement of vascular beds as that is a contraindication.
Major limitation of the study included that the extent of the FMD ,and whether reconstructive surgery done or not and also the outcome of recipient not mentioned in the study.
At our center, donors with FMD not considered for donation. What is the level of evidence provided by this article?
Level of evidence 3 (retrospective cohort study).
Wee Leng Gan
2 years ago
This is an observational cohort study with level 3 evidence to compared the development of hypertension, cardiovascular disease (CVD), proteinuria and reduced estimated glomerular filtration rate (eGFR) in among kidney donors with FMD. There were 8922 live kidney donations at the three centers between 1963 and 2007 of which 113 donors had FMD. Donors with FMD were older (51 versus 39 years), were more likely to be women (80% versus 56%) and had a higher systolic blood pressure at donation (124.7 versus 121.3 mmHg) (P< 0.05 for all). After a mean 6 standard deviation follow-up of 15.5 6 8.9 years, a similar proportion of donors with and without FMD were alive, and developed hypertension (22.2% versus 19.8%), proteinuria (20.6% versus 13.7%) and CVD (13.3% versus 13.5%). No donor with FMD developed an eGFR <30 mL/min/1.73 m2 or end-stage kidney disease. The multivariable risk of mortality, CVD and renal outcomes in donors with FMD was not elevated. Strengths include largest series of kidney donors with FMD that has been studied and with the longest follow-up. The limitations include the extent of FMD (unilateral versus bilateral, unifocal versus multifocal) is not captured in the dataset. In addition, there is no information about the three participating centers’ approach to donors with FMD. In conclusion, kidney donors with FMD appear to do well, do not appear to incur increased risks of hypertension, proteinuria, CVD or reduced eGFR.
Wadia Elhardallo
2 years ago
Ø Study conducted in 3 centres in USA addressed long-term outcomes of 8922 kidney donors who donated between 1963 and 2007
Ø Compared the development of hypertension, cardiovascular disease (CVD), proteinuria and reduced estimated glomerular filtration rate (eGFR) in 113 kidney donors with FMD discovered during donor evaluation versus 452 propensity score matched donors without FMD
Ø Donors with FMD had a higher systolic blood pressure at donation (124.7 versus 121.3 mmHg) (P< 0.05 for all). After a mean 6 standard deviation follow-up of 15.5 6 8.9 years, a similar proportion of donors with and without FMD were alive, and developed hypertension (22.2% versus 19.8%), proteinuria (20.6% versus 13.7%) and CVD (13.3% versus 13.5%).
Ø No donor with FMD developed an eGFR <30 mL/min/1.73 m2 or end-stage kidney disease.
Ø The multivariable risk of mortality, CVD and renal outcomes in donors with FMD was not elevated
Ø Donor with FMD appear to do well, do not appear to incur increased risks of hypertension, proteinuria, CVD or reduced eGFR.
Level 3
Theepa Mariamutu
2 years ago
The Renal and Lung Living Donor Evaluation (RELIVE) study involved 8922 living renal donors from 1963 to 2007, included 8922 living renal donors from 1963 and 2007 were assorted as FMD (113) and without FMD (8809). Donors with FMD were found to be older (51 against 39 years), mostly women (80% vs 56%) and White (90.3% vs 84.7%) with significant p value (P<0.05 for all).
Baseline eGFR was even detected lower in donors with FMD in comparison to non-FMD (79 versus 88mL/min/1.73m2, P<0.001).
Incidence of associated family history of hypertension was higher, besides open nephrectomy for right kidney with single arterial supply compared to non-donated kidneys in donors with FMD.
Mean follow-up of 15.568.9 years and donors without FMD developed CVD by 13.5%, 19.8% hypertension, 13.7% proteinuria and 0.6% ESKD in comparison to donors with
FMD have never developed eGFR<30mL/min/1.73m2 or ESKD except more prone to develop proteinuria (20.6 versus 13.7%) (P=0.04).
The estimated risk of mortality in donors with FMD was 0.64 (0.11, 3.65) (P=0.61), whereas CVD was 1.04 (0.36, 2.97) (P=0.95).
Risks of hypertension or proteinuria or eGFR decline <60mL/min/1.73m2 were not significant.
Donors with FMD were less likely to develop CVD or HTN or proteinuria or renal impairment. FMD clinically involved the renal arteries in 75%, 74% of the carotid arteries and 33% of the vertebral arteries in these cases.
Patients with FMD can be complicated by hypertension or even 35% develop stroke or transient ischemic attack because of carotid and vertebral artery dissection. Study suggested the necessity to perform onetime head-to-pelvic cross-sectional vascular imaging with CT angiography.
Study conducted by the Mayo Clinic including 2250 donors; 38 had FMD with concurrent bilateral disease in only 14 cases. Follow up after 16.6 years of donors with FMD demonstrated that similar blood pressure and urinary protein excretion to those in donors without FMD. The long-term recipient outcomes from FMD donors did not differ from recipients of non-FMD kidneys according to their study.
The incidence of involvement of the right renal artery is greater than the left 33.8% vs 11.6% of unilateral FMD cases. There were no associated differences in the prevalence of kidney cysts or stones in the donated and non-donated kidneys in both groups.
Strengths
largest series of kidney donors with FMD with the longest follow-up
Limitations
sub classification of FMD either unilateral or bilateral and unifocal or multifocal
Data concerning the reconstruction of the FMD vessel was ever performed in the recipient was deficient.
Kidney donors with FMD can still safely donate as their long-term incidence of mortality, CVD and hypertension, and reduced eGFR is similar to the general donor population. Candidate donors with FMD should be monitored annually for detection of hypertension and renal functions decline.
What is the level of evidence provided by this article?
Level of evidence: III.
Hinda Hassan
2 years ago
The Renal and Lung Living Donor Evaluation (RELIVE) study addressed long-term outcomes of 8922 kidney donorswhodonatedbetween1963and2007.Wecomparedthe development of hypertension, cardiovascular disease (CVD), proteinuria and reduced estimated glomerular filtration rate (eGFR) in 113 kidney donors with FMD discovered during donor evaluation versus 452 propensity score matched donors without FMD. Outcomes modeling with logistic and Cox regression analysis and Kaplan–Meier statistics were performed. Results. Donors with FMD were older (51 versus 39years), were more likely to be women (80% versus 56%) and had a higher systolic blood pressure at donation (124.7 versus 121.3mmHg)(P<0.05forall).Afteramean6standarddeviation follow-up of 15.568.9years, a similar proportion of donorswithandwithoutFMDwerealive,anddevelopedhypertension (22.2% versus 19.8%),proteinuria(20.6% versus13.7%) and CVD (13.3% versus 13.5%). No donor with FMD developed an eGFR <30mL/min/1.73 m2 or end-stage kidney disease. The multivariable risk of mortality, CVD and renal outcomesindonorswithFMDwasnotelevated. Conclusions. Kidney donors with FMD appear to do well, do notappeartoincurincreasedrisksofhypertension,proteinuria, CVD or reduced eGFR, and perhaps carefully select
There were 8922 live kidney donations at the three centers between 1963 and 2007 (Figure 1). The characteristics of donors with FMD (n¼113) and those without FMD (n¼8809) are presented in Table 1. Donors with FMD were older (51 versus 39years), and were more likely to be women (80% versus 56%) and White (90.3% versus 84.7%) (P<0.05 for all). Baseline eGFR was also lower in donors with FMD (79 versus 88mL/ min/1.73m2,P<0.001). Open nephrectomy, right kidney donation and likelihood of the remaining kidney having just one artery were significantly higher in donors with FMD. In the propensity score matched comparison the two groups were highlycomparableexceptforahigherlikelihoodofhavingfamily history of hypertension, undergoing open nephrectomy,
right kidney removal and having a singular artery in the nondonatedkidneysindonorswithFMD(Table2). Vitalstatuswasascertainablein99.8% ofdonorsasof2010– 12.CVDdevelopmentwasascertainablein98%,diabetesdevelopment in 90.2%, urinary protein assessment and proteinuria status in 89.9%, and eGFR values in 97.1%. Cause of death was availableforroughly 50% ofalldonors. Therewerenodifferencesinthedistribution ofcause of death betweenthetwo groups (data not shown). Regarding CVD incidence: myocardial infarction, stroke, transient ischemic attacks, heart failure and need for coronary revascularization were similar between donorswithandwithoutFMD. After a mean follow-up of 15.568.9years, 13.5% of donors without FMD developed CVD, 19.8% developed hypertension, 13.7% developed proteinuria and 0.6% developed ESKD (Table 3A). The corresponding proportions in donors with FMD were 13.3, 22.2 and 20.6%, and none developed eGFR <30mL/min/1.73m2 or ESKD. Donors with FMD, compared with the entire donor cohort without FMD, were more likely to develop proteinuria (20.6 versus 13.7%) (P¼0.04). In the propensity matched score analysis; however, there were no differences between the two donor groups on any of the outcomes studied,includingproteinuria(Table3B).The cumulativemortality incidence, CVD, hypertension, proteinuria, and eGFR <60 and <45mL/min/1.73m2 are provided in Table 4. Figure 2 depicts the Kaplan–Meier estimates of the different outcomesThe multivariable risk of mortality in donors withFMD was 0.64 (0.11, 3.65) (P¼0.61) and that of CVD was 1.04 (0.36, 2.97) (P¼0.95). Similarly, the risks of hypertension, proteinuria, eGFR <60mL/min/1.73m2 and eGFR <45mL/min/ 1.73m2 werenotelevated,either(Table5).Theresultsfromthe
logistic and Cox regression models were highly concordant for alloutcomes.
level of evidence II
Jamila Elamouri
2 years ago
Long-term outcomes of kidney donors with fibromuscular dysplasia
Fibromuscular dysplasia (FMD) is a non-atherosclerotic arterial disease of unclear cause. It due to abnormal cellular proliferation and disruption of the arterial wall structure, and manifested by dissection, aneurysm and tortuosity of many vascular beds. FMD is encountered in 2.0–6.6%
of kidney donors during evaluation of renal vasculature. There are only few case series that address the outcome of donors with FMD, resulting in stroke, myocardial infarction and peripheral arterial disease.
Aim:
studied the development of hypertension, cardiovascular disease (CVD), proteinuria and reduced estimated GFR (eGFR) in a large cohort of kidney donors with FMD.
Methods.
The Renal and Lung Living Donor Evaluation (RELIVE) study addressed long-term outcomes of 8922 kidney donors who donated between 1963 and 2007. We compared the development of hypertension, cardiovascular disease (CVD), proteinuria and reduced estimated glomerular filtration rate (eGFR) in 113 kidney donors with FMD discovered during donor evaluation versus 452 propensity score matched donors without FMD. Outcomes modeling with logistic and Cox regression analysis and Kaplan–Meier statistics were performed.
Results:
FMD donors are more likely to be women, had high blood pressure at donation. After a mean follow-up of 15.5 ± 8.9 years, similar proportion of donors with and without FMD were alive, and developed hypertension, proteinuria and CVD.
No donor with FMD developed an e GFR < 30 ml/min/1.73m2. or ESRD.
DISCUSSION
kidney donors who had FMD in the donated kidney at the time of kidney donation were not more likely to develop hypertension or adverse cardiovascular or renal consequences. FMD affects renal arteries in 75%, the carotid arteries in 74% and 33% of the vertebral arteries. Patient with FMD present with hypertension and stroke or TIA secondary to carotid and vertebral artery dissection. These observations have led to the recommendation that once a FMD diagnosis is made, patients should have one-time head-to-pelvic cross-section vascular imaging with CT angiography, this recommendation exist since 2012. Moreover, long-term recipient outcomes from FMD donors did not differ from recipients of non-FMD kidneys.
Strength of the study:
1- Largest study
2- The outcomes of interest were ascertainable in the majority of donors.
Limitations:
The extent of FMD is not determined in the dataset.
It is possible that the donors with FMD who were included in the analysis had mild disease.
They suspect that if these donors had FMD involving the visceral arterial bed or the iliac arteries they would have been excluded, as these regions are included in the routine angiographic imaging of kidney donors.
No data about the recipient from FMD donor.
Conclusion:
In all, these data demonstrate that some kidney donors with FMD can safely donate as their long-term incidence of mortality, CVD and hypertension, and reduced eGFR is similar to the rest of the donor population.
Recommendation regarding assessment of all vascular beds for the presence of FMD should be strongly considered in donors with FMD.
Recipient with multiple donors, FMD donor should be considered last and the kidney with mild disease is chosen.
if donor candidates with FMD are to be accepted they should be seen at least annually for early hypertension detection and signs of kidney function decline.
Ahmed Omran
2 years ago
It is the largest series of donor with FMD. FMD is a non-atherosclerotic arterial disease of medium arteries that is due to abnormal proliferation of arterial wall structure.
It was seen in 2.0 – 6.6% of renal donors.
Its a retrospective study done to evaluate the development of hypertension, proteinuria, CVD, and diminished GFR in donors with FMD.
After follow up of 15 years ,no difference was found in mortality, CVD, hypertension, proteinuria, decreased GFR between donors with and with out FMD.
I t was concluded that some donors with FMD can donate safely, after exclusion of extrarenal vessel involvement, as 35% of patient with FMD can develop stroke/TIA. FMD donors should be monitored at least annually for hypertension.
Study has level of evidence III.
Hamdy Hegazy
2 years ago
Please summarize this article in your own words This is a retrospective study where data was collected from the RELIVE study (Renal and Lung Living Donor Evaluation) which studied the long-term outcomes of 8922 Kidney donors between 1963-2007. DATA from 3 transplant centers. 113 kidney donors with FMD were found during evaluation of donors who developed HTN, CVD, proteinuria and dropped GFR. These donors were evaluated against 452 score matched donors without FMD. FMD was more common in older, female donors with pre-donation high systolic BP. Donors with FMD were followed for 15 years, they were found to have more hypertension, proteinuria and CVD. None of these donors developed GFR below 30 ml/min/m2 or ESRD. Limitations: 1- The extent of FMD was not studied including unilateral vs bilateral or multifocal vs unifocal. 2- Missing data about the participating centers and their data about donors with FMD. 3- No clear data about reconstruction of FMD vessel in the recipients. 4- No data about the recipients’ outcomes.
What is the level of evidence provided by this article? Level of evidence III
Ahmed Abd El Razek
2 years ago
Introduction
Fibromuscular dysplasia (FMD) is caused by abnormal cellular proliferation and disruption of the arterial wall structure, which can be complicated by dissection, aneurysm and tortuosity of variable vascular beds mainly renal, carotid, visceral, external iliac arteries up to coronary arteries.
FMD was discovered to be of 2.0–6.6% incidence during routine assessment for renal donation. Other previous studies had small number of FMD donors with short period follow up regarding the development of complications as cardiovascular disease or hypertension or renal function decline and renal impairment in the form of proteinuria.
Materials and methods
The Renal and Lung Living Donor Evaluation (RELIVE) study involved 8922 living renal donors from 1963 to 2007. CVD included the occurrence of myocardial infarction, congestive heart failure, transient ischemic attack, stroke, or need for coronary or peripheral arterial intervention (angioplasty, stenting or bypass). Proteinuria detected by dipstick exceeded 2 +, urine protein/osmolality >0.42 ratio, urine random protein >15mg/dL or 24-h protein >300mg/day is considered.
At time of donation, donors were medically free regarding proteinuria or renal impairment. Establishment of FMD diagnosis was accepted on the presence of at least one focal or multifocal arterial lesion.
Statistical analysis
Hypertension, proteinuria, eGFR <60mL/min/1.73 m2, <45mL/min/1.73 m2 and <30mL/min/1.73 m2, and CVD development were compared in donors with FMD (case) to donors without FMD (control).
P-value of <0.05 was considered statistically significant.
Results
The included 8922 living renal donors from 1963 and 2007 were assorted as FMD (113) and without FMD (8809). Donors with FMD were found to be older (51 against 39 years), mostly women (80% vs 56%) and White (90.3% vs 84.7%) with significant p value (P<0.05 for all).
Baseline eGFR was even detected lower in donors with FMD (79 versus 88mL/min/1.73m2, P<0.001).
According to this study, the incidence of associated family history of hypertension was higher, besides open nephrectomy for right kidney with single arterial supply compared to non-donated kidneys in donors with FMD.
Data revealed that after a mean follow-up of 15.568.9 years, about donors without FMD developed CVD by 13.5%, 19.8% hypertension, 13.7% proteinuria and 0.6% ESKD.
While donors with FMD have never developed eGFR<30mL/min/1.73m2 or ESKD. However, they were more prone to develop proteinuria (20.6 versus 13.7%) (P=0.04).
The estimated risk of mortality in donors with FMD was 0.64 (0.11, 3.65) (P=0.61), whereas CVD was 1.04 (0.36, 2.97) (P=0.95). Interestingly, the risks of hypertension or proteinuria or eGFR decline <60mL/min/1.73m2 were not significant.
Discussion
According to this study, donors with FMD were less likely to develop CVD or HTN or proteinuria or renal impairment. FMD clinically involved the renal arteries in 75%, 74% of the carotid arteries and 33% of the vertebral arteries in these cases. Patients with FMD can be complicated by hypertension or even 35% develop stroke or transient ischemic attack as a consequence of carotid and vertebral artery dissection. This fact suggested the necessity to perform onetime head-to-pelvic cross-sectional vascular imaging with CT angiography.
An informative study conducted by the Mayo Clinic including 2250 donors; 38 had FMD with concurrent bilateral disease in only 14 cases. Follow up after 16.6 years of donors with FMD demonstrated that similar blood pressure and urinary protein excretion to those in donors without FMD. The long-term recipient outcomes from FMD donors did not differ from recipients of non-FMD kidneys according to their study.
The incidence of involvement of the right renal artery is greater than the left 33.8% vs 11.6% of unilateral FMD cases. There were no associated differences in the prevalence of kidney cysts or stones in the donated and non-donated kidneys in both groups.
Strengths of this project is being the largest series of kidney donors with FMD with the longest follow-up. Limitations were mainly the sub classification of FMD either unilateral or bilateral and unifocal or multifocal. Data concerning the reconstruction of the FMD vessel was ever performed in the recipient was deficient.
They concluded that, kidney donors with FMD can still safely donate as their long-term incidence of mortality, CVD and hypertension, and reduced eGFR is similar to the general donor population. Candidate donors with FMD should be monitored annually for detection of hypertension and renal functions decline.
Level of evidence: III.
Ahmed Fouad Omar
2 years ago
Introduction:
Fibromuscular dysplasia (FMD)is non-atherosclerotic arterial disease due to abnormal endothelial cell proliferation disease causing arterial wall aneurysms and disruption manifested by dissection tortuosity of vascular beds.
It affects the renal arteries in 75% of the cases, 74% of the carotid arteries and 33% of the vertebral arteries.
FMD is found in 2-6.6% of kidney donors .
This is a retrospective study that included participants from the Renal and Lung Living Donors (RELIVE).It included 8922 kidney donors between 1963 and 2007. The study compared the development of hypertension, CVD, proteinuria and reduced estimated glomerular filtration rate (eGFR) in 113 kidney donors with FMD discovered during donor evaluation versus 452 matched donors without FMD.
Outcome
Kidney donors with FMD have no increased risks of hypertension, proteinuria, CVD or reduced eGFR.
Limitations:
The extent of FMD is not captured in the dataset and the centers approach to donors with FMD, disease severity, other vessels involvement was not mentioned.
The outcomes of the recipients was not available and it is also not clear whether reconstruction of the FMD vessel was performed in the recipient.
Level of evidence:
Level 3, retrospective cohort study
This is the largest ever series of donor with FMD that has been studied. FMD is a non-atherosclerotic arterial disease of medium vessels that is secondary to abnormal proliferation of arterial wall structure.
It was seen in 2.0 to 6.6% of renal donors.
Its a retrospective study conducted to evaluate the development of hypertension, proteinuria, CVD, and reduced GFR in donors with FMD.
After follow up of 15+_ years there was no differences in mortality, CVD, Hypertension, proteinuria, decreased GFR between donors with and with out FMD.
According to data concluded that some donors with FMD can donate safely, after exclusion extrarenal vessel involvement, because 35% of patient with FMD can develop stroke/TIA. FMD donors should be followed at least annually for hypertension.
Level of evidence III.
Abdulrahman Ishag
2 years ago
The aim o the study ;
———————————
Was to study the development of hypertension, cardiovascular disease (CVD), proteinuria and reduced estimated GFR (eGFR) in kidney donors with FMD.
The type o the study ;
————————————
Retrospective cohort study .
Ethical approval;
—————————-
This study was exempt from Institutional Review Board approval as it used de-identified donor information that is publicly available.
Population ;
——————
1-The study group;113 kidney donors with FMD discovered during donor evaluation .
2-Controlled group; 452 propensity score matched donors without FMD.
Results;
———————-
After 15.5 +_ 8.9 years of follow-up, there were no differences in mortality, cardiovascular disease, hypertension development, proteinuria or reduced kidney function between donors with and without FMD.
The strengths of the study;
————————————-
It is the largest series of kidney donors with FMD that has been studied and with the longest follow-up.
The limitations;
————————————
1-The extent of FMD (unilateral versus bilateral, unifocal versus multifocal) is not captured in the data set.
2- There is no information about the three participating centers’ approach to donors with FMD.
Conclusion;
—————————–
1-These data demonstrate that some kidney donors with FMD can safely donate as their long-term incidence of mortality, CVD and hypertension, and reduced eGFR is similar to the rest of the donor population.
2-Newly introduced recommendations regarding assessment of all vascular beds for the presence of FMD should be strongly considered when donors with FMD are considered for kidney donation.
3- In recipients with multiple potential donors, the ones with FMD can perhaps be considered last. Importantly, if donor candidates with FMD are to be accepted they should be seen at least annually for early hypertension detection and signs of kidney function decline.
What is the level of evidence provided by this article?
————————————————————————
Level 11I
Shereen Yousef
2 years ago
▪︎Introduction
Fibromuscular dysplasia (FMD) is a non-atherosclerotic arterial disease .
it causes abnormal cellular proliferation and disruption of the arterial wall structure.
It affect many vascular beds such as the renal, carotid, visceral, external iliac arteries and even the coronary arteries .
It usually manifests wigh stroke, hypertension, or myocardial infarction.
FMD is encountered in 2.0–6.6% of kidney donors during evaluation of renal vasculature.
Method
The study was conducted to evaluated the development of hypertension, CVD, proteinuria and reduced eGFR in donors with FMD.
retrospective cohort study included 9822 living donors
dara collected from RELIVE from 1963 to 2007 .
113 kidney donors with FMD discovered during donor evaluation versus 452 propensity score matched donors without FMD.
On follow up for 15.5 6 8.9 years,
The study compared donors with FMD with non-FMD donors with main baseline characteristics of age, sex, eGFR
▪︎Results ,-Donors with FMD were older (51 versus 39) years, mostly were women(80%).
FMD donors had higher systolic BP and had lower baseline eGFR 79 versus 88 mL/ min/1.73 m2 the outcomes of kidney donors with FMD compared to those without ,there were no differences in mortality, cardiovascular disease, hypertension, proteinuria or reduced kidney function between donors with and without FMD.
▪︎strengths of the study
-largest number of kidney donors with FMD that has been studied .
– the longest follow-up.
▪︎limitations of the study
– The extent of FMD (unilateral versus bilateral, uni-focal versus multifocal) is not determined
– there is no information about the three participating centers.
-It is possible that the donors with FMD who were included in the analysis had mild disease, since perhaps individuals with severe disease were not allowed to donate.
-Not clear whether reconstruction of the FMD vessel was performed in the recipient.
– no data on the outcomes of the recipients of the donated kidney.
▪︎conclusion
FMD can safely donate their kidneys after the exclusion of extrarenal vascular beds involvements. FMD can safely donate as their long-term incidence of mortality, CVD and hypertension, and reduced eGFR is similar to the rest of the donor population recommendations regarding assessment of all vascular beds for the presence of FMD should be strongly considered when donors with FMD are considered for kidney donation. FMD donors should be seen at least annually for early hypertension detection and signs of kidney function decline.
Hussam Juda
2 years ago
INTRODUCTION
· fibromuscular dysplasia (FMD) of the renal artery is associated with hypertension and involves many vascular beds resulting in stroke, myocardial infarction and peripheral arterial disease
· FMD can be found in 2.0–6.6% of kidney donors during evaluation of renal vasculature
· Aim of the study: a comparison of the outcomes of kidney donors with FMD to those without
MATERIALS AND METHODS
· Study included 3 centers in USA
· Renal and Lung Living Donor Evaluation (RELIVE) Study, involved 8922 live kidney donations
from 1963 to 2007 with follow up data 2010-2012
· Donors with FMD compared to those without FMD
· Outcomes: cardiovascular disease, HTN, and reduced GFR
· Definitions:
– CVD: myocardial infarction, congestive heart failure, transient ischemic attack, stroke, or need
for coronary or peripheral arterial intervention
-End-stage kidney disease (ESKD): the need for dialysis, or receiving or being listed for a kidney
transplant.
-Proteinuria: urine protein by dipstick 2+, urine protein/osmolality >0.42 ratio, urine random
protein >15 mg/dL or 24-h protein >300 mg/day
· Exclusion criteria:
1- donors with proteinuria,
2- measured GFR or creatinine clearance <80 mL/min RESULTS
· Donors with FMD were older, and were more likely to be women and White.
· Baseline eGFR was lower in donors with FMD
· Open nephrectomy, right kidney donation and likelihood of the remaining kidney having just one artery were significantly higher in donors with FMD.
· There were no differences in the distribution of cause of death between the two groups
· CVD incidence was the same between donors with and without FMD
DISCUSSION
· kidney donors with FMD in the donated kidney at the time of kidney donation, didn’t develop hypertension or adverse cardiovascular or renal consequences
· patients with FMD present with HTN and 35% may present with stroke or TIA secondary to carotid and vertebral artery dissection
· Donors with FMD were less likely to donate the left kidney
· Strength of the study: large number of donors and long follow up.
· Limitations:
1-The extent of FMD is not captured in the dataset.
2-there is no information about the three participating centers’ approach to donors with FMD.
3-It is possible that the donors with FMD who were included in the analysis had mild disease, since perhaps individuals with severe disease were not allowed to donate
4- donors with FMD involving the visceral arterial bed or the iliac arteries could have been excluded
5- It is not clear whether reconstruction of the FMD vessel was performed in the recipient.
6-There are no available data on the outcomes of the recipients of the donated kidney
CONCLUSION
· Kidney donors with FMD are doing well, and have no increased risk of HTN, CVD, or reduced GFR.
· Candidates with FMD can donate their kidney safely, if they were selected carefully
What is the level of evidence provided by this article?
Retrospective study level 3
saja Mohammed
2 years ago
Background
Fibromuscular dysplasia (FMD) of the renal arteries is considered one of the causes of renovascular hypertension, it’s categorized by abnormal cellular proliferation and alteration of the arterial wall structure and can exist with dissection, aneurysm, and tortuosity of many vascular beds in the kidneys, carotids, visceral, external iliac vessels and coronaries lead to stroke, hypertension, heart attacks and peripheral vascular diseases it can be found in smaller numbers of potential kidney donors with uncertain consequences on long-term outcomes. Aim of the study
To assess the outcome of donations from people with known FMD in terms of reduced e GFR, CVD, proteinuria, and hypertension Method
A retrospective observational cohort study from 3 centers in the USA data collected from RELIVE from the period of 1963-2007 and FU data from 2010-2012, a total of > 9822 living donors included in this study and compared donors with FMD with non-FMD donors with main baseline characteristics of age, sex, e GFR with target outcome of CVD, HTN, proteinuria, and ESRD. Median follow-up period 15.5+/- 8.9 years.
Results
FMD was found in 113 of the FMD donors with a mean age of 51 years older than the no FMD donors (452) with a mean age of 39, the majority (80%vs 56%) of FMD donors were females with higher systolic BP at donation time lower baseline e GFR 79ml/min/1.73 m2
But upon the follow-up period, both have similar survival rates and similar rates of hypertension and CVD, and no donor with FMD develops advanced CKD including ESKD. Even with multivariable risk adjustment for mortality, CVD, and ESKD.
Discussion
This observational cohort study confirms the safety of donation from isolated renal FMD candidates with no significant long-term impact on the donor and also the recipient in terms of risk of HTN, proteinuria, CVD, or progressive reduction in e GFR. which is similar to the finding from previous few studies including case series and small sample size with short FU period, however, few cases report it dose address the higher rate of Hypertension in FMD donors. Conclusion
FMD kidney donors on long-term FU doing well without increased risk of HTN, proteinuria, CVD, and ESKD, with the vigilant selection still donors with FMD can safely donate their kidneys after the exclusion of extrarenal vascular beds involvements.
Strength of this study
Large cohort with good sample size and a long follow-up period and the outcome of interest was discoverable in the majority of donors Limitations of this study
Missing data about the FMD details focal vs multifocal, unilateral, or bilateral
No clear exclusion criteria from the 3 participating centers about the severity of FMD in their donors.
Missing data about the recipient’s outcome
What is the level of evidence provided by this article?
level 3 retrospective cohort study
Last edited 2 years ago by saja Mohammed
Muntasir Mohammed
2 years ago
1. Please summarise this article in your own words Introduction Fibromuscular dysplasia (FMD) is a non-atherosclerotic arterialdisease of unclear cause.
In FMD there is abnormal cellular growth with leading to arterial wall disruption which is appears as disruption of the arterial wall structure, and is manifested by dissection, aneurysm and tortuosity of many vascular beds such as the renal, carotid, visceral, external iliac arteries and even the coronary arteries. It is found to be in 2-6.6% of kidney donors.
Methods.
The Renal and Lung Living Donor Evaluation (RELIVE) study studied long-term outcomes of 8922 donors between 1963 and 2007. We compared the development of hypertension, cardiovascular disease (CVD), proteinuria and reduced estimated glomerular filtration rate (eGFR) in 113 kidney donors with FMD discovered during donor evaluation versus 452 propensity score matched donors without FMD.
Results
Age of donors with FMD (51 versus 39 years), they were more likely to be women (80% versus 56%) and had a higher systolic blood pressure at donation (124.7 versus 121.3mmHg) (P<0.05 for all).
After follow-up of 15.5 years, a similar proportion of
donors with and without FMD were alive, and developed hypertension
(22.2% versus 19.8%), proteinuria (20.6% versus 13.7%)
and CVD (13.3% versus 13.5%). No donor with FMD developed
an eGFR <30mL/min/1.73 m2 or end-stage kidney disease.
Conclusion:
Donor kidneys with FMD can be transplanted safely if involvement of other vascular bed is ruled out.
What is level of evidence?
Level 111
Yashu Saini
2 years ago
Fibromuscular dysplasia (FMD) is not uncommon in prospective kidney donors but long term outcomes are not very clear. It is being postulated that there could be association of FMD with hypertension and /or vascular diseases.
Currently, there are no guidelines regarding recommendations on use of kidneys from donors with FMD.
METHODS
This study used data from the RELIEVE study. No separate case -controls recruitment was done in the study. 113 kidney donors with FMD were selected as cases and 452 controls were selected who were propensity score matched donors.
RESULTS
Donors with FMD were older and more likely females.
They had higher systolic BP at the time of donation
There were no differences in mortality, cardiovascular disease and proteinuria between donors with FMD vs no FMD
LIMITATIONS
Small sample size
Short follow up
Lack of outcome data regarding cardiovascular events
STRENGTHS
This is largest series of kidney donors with FMD
Outcomes of interest were asertainable in majority of donors.
CONCLUSION
Overall the study concluded that kidney donors with FMD can safely donate kidneys and their long term outcomes of cardiovascular events and falling eGFR is no different from those without FMD
Level of evidence 3
Abdul Rahim Khan
2 years ago
Please summarise this article in your own words.
Fibromuscular dysplasia FMD is an important entity in which there is non atherosclerotic arterial disease characterized by abnormal cell proliferation and arterial wall damage . It can present as torturous vessels, aneurysms and dissections. The awareness about FMD comes from First international Consensus on FMD. Incidence varies from 2-6% in kidney donors and approach is variable among transplant centres.
Current guidelines do not give clear directions about donation with FMD and there is paucity of data. This study evaluated the effect of kidney donation with FMD .
The Renal and Lung Living Donor evaluation RELIEVE evaluated the outcome of donation with FMD
Total donors- 8922
From 1963-2007
Those with FMD- 114 vs 452 Propensity matched donors.
Donors with FMD were mostly White females and 12 year older. Blood pressure was higher in donors with FMD
They found that there was no increases risk of hypertension, CKD/ESRD and Cardiovascular disease in FMD group as compared to controls.
Conclusion-
Kidney donation with the presence of FMD do well and do not increase the risks of hypertension, CVD, Proteinuria or low GFR in selected cases. Safe kidney donation is possible as long as other vascular trees are carefully assessed.
Post donation a follow up for blood pressure and renal functions is mandatory
What is the level of evidence provided by this article?
Retrospective Cohort study Level 111
Sahar elkharraz
2 years ago
This article is large cohort study done in 3 centres between 1963 to 2007; address outcome of fibromuscular dysplasia in kidney donor.
Fibromuscular dysplasia is non atherosclerotic systemic arterial disease of unknown causes.
FMD is renal artery stenosis may complicated to hypertension and proteinuria and decrease eGFR.
It’s consequences may progress to myocardial infarction and stroke and peripheral vascular disease.
It’s characteristic by cellular proliferation and disruption of arterial wall structure.
It’s may lead to dissection / aneurysm and tortuosity of vascular bed ( renal, cartoid, visceral, external iliac artery and coronary arteries).
It’s account 2 – 6.6% of kidney donor during evaluation.
It’s graded to ( I – IV ), according to severity; grade I mild/ grade IV severe.
This article shows no evidence of hypertension or proteinuria within 4 years of fallow up.
However after 15 years from fallow up there is no difference in change mortality regarding cardiovascular disease and hypertension.
This study recommended accept patients with FMD for donation and counselling regarding restrict fallow up.
Criteria of selected donor in this article is history included family history of hypertension and cardiovascular disease and diabetes and ESRD.
Cardiovascular disease means evidence of stroke and CCF and myocardial infraction.
The donor selected with no evidence of hypertension and diabetes and no proteinuria with eGFR >80 ml/min.
All donor do renal imagine (prior to 1999). was done by conventional angiography and CT angiography and MRA.
Note that fibromuscular dysplasia mainly unilateral and in right kidney more than left, it’s may be genetic in white female, so this females should excluded from donation.
Limitations of this study is small size group of FMD and short fallow up and no data regarding site of FMD.
W2: Level 3
Zahid Nabi
2 years ago
Fibromuscular dysplasia (FMD) is a noninflammatory, nonatherosclerotic disorder that leads to arterial stenosis, occlusion, aneurysm, dissection, and arterial tortuosity. These findings have been observed in nearly every arterial bed Patients with FMD have involvement of the renal arteries approximately 75 to 80 percent of the time and involvement of the extracranial cerebrovascular arteries (eg, carotid and vertebral arteries) approximately 75 percent of the time (UpToDate). In the past, it was believed that FMD was a disease of young women. However, older individuals account for a large proportion of affected patients in several cohorts. As an example, in the United States FMD Registry, the mean age at diagnosis was 52 years, with a range of 5 to 97 years
The authors of this study have touched a very delicate issue. Shall we accept donors with FMD or no?
The Renal and Lung Living Donor Evaluation (RELIVE) study addressed long-term outcomes of 8922 kidney donors who donated between 1963 and 2007.
They compared the development of hypertension, cardiovascular disease (CVD), proteinuria and reduced estimated glomerular filtration rate (eGFR) in 113 kidney donors with FMD discovered during donor evaluation versus 452 propensity score matched donors without FMD.
Outcomes modeling with logistic and Cox regression analysis and Kaplan–Meier statistics were performed.
Donors with FMD were older (51 versus 39years), were more likely to be women (80% versus 56%) and had a higher systolic blood pressure at donation (124.7 versus 121.3 mmHg) (P < 0.05 for all).
After a mean 6 standard deviation follow-up of 15.5 6 8.9 years, a similar proportion of donors with and without FMD were alive, and developed hyper- tension (22.2% versus 19.8%), proteinuria (20.6% versus 13.7%) and CVD (13.3% versus 13.5%). No donor with FMD developed an eGFR <30 mL/min/1.73 m2 or end-stage kidney disease.
Kidney donors with FMD appear to do well, do not appear to incur increased risks of hypertension, proteinuria, CVD or reduced eGFR, and perhaps carefully selected.
In view of findings of current study candidates with FMD can safely donate as long as involvement of other vascular beds is ruled out.
It is a retrospective observational cohort study. Level 3
Marius Badal
2 years ago
Please summarise this article in your own words
What is the level of evidence provided by this article?
The article is based on the long-term outcomes of kidney donors with fibromuscular dysplasia (FMD). FMD is a pathology that is a non-atherosclerotic arterial disease with an unknown etiology. It is a disease that is found in about 2.0-6.6% of kidney donors during the investigation or study for possible kidney donors. The study was conducted by RELIVE with a population of 8922 kidney donors from a period of 1963-2007. The donors were followed up who had CVD, BP and proteinuria, and GFR.
During the investigation, it was found that 80% of females had FMD and were older donors. There was significantly elevated BP and decreased GFR in donors than in non-FMD donors. There was a right kidney donation with FMD. It was noted that CVD, DM, low GFR, and the level of proteinuria were the likely contributing cause of death in the two groups studied. As it related to having proteinuria it was found more frequently in the FMD donors than the non-FMD donors. The FMD never had a decrease of GFR in a severe manner and neither has ESRD.
The study was the largest group of FMD ever studied and with the longest follow-up. However, there were some limitations such as there no clear understanding as to the extent of the FMD and the number of vessels affected. There was no data to compare the outcome when relate to the recipients.
So one can conclude that donors with FMD can donate safely since their long-term outcomes are similar to other donors. After a long period of follow-up, FMD donors had similar proteinuria and BP when compared with non-FMD donors.
The level of evidence in this study was level 3
Manal Malik
2 years ago
1-Summary of this article
Introduction
FMD is anon atherosclerotic arterial disease of unclear cause ,FMD is encounted in 2% -6% of kidney donors during evaluation of renal vasculature .
The goal of this analysis was to ascertain cardiovascular outcome since FMD is not confined to renal arteries and can lead to acute myocardial infraction and peripheral arterial disease
Method
The RELIVE study rolled 8922 live kidney donors from 1963 to 2007 donors with FMD are 113,family history of HTN ,DM ,kidney disease ,stroke or heart disease in donor first degree was recorded.
Result
113 donor with FMD ,in the propensity score matched comparison the two groups were highly comparable except for a higher like hood of family history of HTNA undergoing open nephrectomy .
CVS incidence ,myocardial infraction ,stroke ,transit ischemic attack, heart failure and need for coronary revascularization were similar between donors with and without FMD.
Discussion
FMD donors at time of kidney donation were not more likely to develop HTN or ad verse CVS or renal consequences.
Donors with FMD were less likely to have the left kidney removed, as right renal artery is more commonly involved with FMD than the left .
Inconclusion ,that some kidney donor with FMD can safely donated as their long -term incidence of mortality ,CVD and HTN and reduced eGFR is similar to the rest of the donor population
Recommendation regarding assessment of vascular bed in donors with FMD.
FMD should be seen at least annually for early HTN detection and sign of kidney function decline.
2- level3 retrospective study
Filipe prohaska Batista
2 years ago
This is a retrospective observational cohort study with three US centers collecting data between 1963 and 2007 (Level of Evidence 2b). The objective is to evaluate the evolution of kidney donors with fibromuscular dysplasia, a non-arteriosclerotic arterial disease of unknown cause. There are questions about development of hypertension, cardiovascular disease, proteinuria, and eGFR reduction.
The study looked at 8922 and contacts between 2010-2012 and identified 113 patients with fibromuscular dysplasia. A 4:1 score matching was performed, separating the groups into 452 and 113 donors. The fibromuscular dysplasia group is more frequent in older, female, Caucasian donors with lower eGFR than the control group. Regarding the results, cardiovascular disease, hypertension, and ESKD do not show a statistically significant difference. They are more likely to develop proteinuria (20.6 x 13.7%).
This study is the largest series of patients with fibromuscular dysplasia and with a very extended follow-up, but there were no records of how extensive the dysplasia was (unilateral, bilateral, multifocal). There was also a lack of data on the surgical procedure performed on the recipient.
The study suggests that donor candidates with fibromuscular dysplasia should be screened annually for early detection of hypertension and signs of loss of kidney function.
mai shawky
2 years ago
Summary:
· Fibromuscular dysplasia (FMD) is systemic vascular disease (not related to atherosclerosis) that can be discovered during work up before organ donation in 0.2-6.6 % of potential living kidney donors. It is characterized by abnormal structure of arterial wall that can affect carotid, renal, coronary and iliac arteries so it is associated with ischemic stroke, hypertension, myocardial infarction and peripheral arterial disease respectively.
· The current observational cohort aimed to compare donors with FMD and those without it, as regard eGFR, hypertension, proteinuria and cardiovascular outcomes as no current guidelines or recommendations in this aspect.
· FMD donors were older age and more commonly females. However, comparable outcomes were found when compared to none FMD donors after a mean of 15 years duration of follow up.
· So, the current study can provide recommendation for accepting some donors with FMD(after exclusion of other vascular site affection and with strict adherence to follow up yearly thereafter for development of hypertension or decline in GFR after donation) in order to expand the donor pool to solve the problem of living organ shortage.
· Exclusion of those who have iliac arteries affection, or having severe disease or bilateral renal artery affection.
· The renal arteries were the most common site of affection (75% of FMD cases), unilateral affection is more common than bilateral, and the right renal artery tended to be more affected than the left one.
· There are many limitations: no available data regarding
o The transplant centers” policy of dealing with FMD donors.
o The long -term outcomes of the recipients of the grafts from FMD donors.
o Pattern of FMD whether focal or multifocal, mild or severe affection.
Level of evidence: retrospective cohort (level III)
Mohammed Sobair
2 years ago
1. Please summarize this article in your own words
Background:
Fibromuscular dysplasia is a non-atherosclerotic arterial disease of unclear cause
Is manifested by dissection, aneurysm and tortuosity of many vascular beds such as the
renal, carotid, visceral, external iliac arteries and even the coronary arteries.
No recommendations regarding the use of kidneys from donors with FMD and there is a
paucity of data on the outcomes of these donors.
Methods.
The Renal and Lung Living Donor Evaluation (RELIVE) study addressed long-term
outcomes of 8922 kidney donors who donated between 1963 and 2007.
Outcome:
The development of hypertension, cardiovascular disease (CVD), proteinuria and
reduced estimated glomerular filtration rate in 113 kidney donors with FMD discovered
during donor evaluation versus 452 propensity score matched donors without FMD.
Results:
Donors with FMD were older, were more likely to be women and had a higher systolic
blood pressure at donation.
After a mean and standard deviation follow-up of 15.5 6 8.9 years, a similar proportion of
donors with and without FMD were alive, and developed hypertension (22.2% versus
19.8%), proteinuria (20.6% versus 13.7%) and CVD (13.3% versus 13.5%).
No donor with FMD developed an eGFR less than 30 or ESRD. Discussion:
Donors with FMD IS more likely to develop hypertension or adverse cardiovascular or
renal consequences.
Conclusions:
Kidney donors with FMD appear to do well, do not appear to incur increased risks of
hypertension, proteinuria, CVD or reduced eGFR; candidates with FMD can safely
donate as long as involvement of other vascular beds is ruled out.
Limitation:
The extent of FMD (unilateral versus bilateral, univocal versus multifocal) is not captured
in the dataset. In addition, there is no information about the three participating centers’
approach to donors with FMD.
It is also not clear whether reconstruction of the FMD vessel was performed in the
recipient.
Lastly, we do not have data on the outcomes of the recipients of the donated kidney.
2. What is the level of evidence provided by this article?
Level of evidence 111
Mahmud Islam
2 years ago
As a retrospective lecture (case-control), it has Level II of evidence. 113 cases of FMD were compared in 1:4 ratio matching. The lowest recorded 3 reading were considered for considering HT (to minimize the white coat effect). source of information is mostly previous records, with a small number of information taken from recipients of those donors. 3 centres participated with information from a total of 8922; 113 of them had FMD. Most participants were white (84.8% non -FMD / 90.3% with FMD).Donors with FMD were older (51 vs 39). and had lower basal eGFR (79 vs 88 ml/min/1.73m2). although the cause of death was ascertainable in 50% of donors, no difference was noted. Coronary artery revascularization also was nearly similar. as we can see in figure 2 (kaplan-Meier), HT was similar /parallel till the 15 years of follow-up but became prominent (higher number) before 20 years. the cardiovascular events were similar, and eGFR was similar on follow-up. As a result, we can conclude that donors with FMD can be acceptable donors in terms of extended pool donation if they are the option available after evaluation.
Rihab Elidrisi
2 years ago
the conclusion of this study is showing that we can accept patient with FMD as a kidney donor as the study showed that After a mean 6 standard deviation follow-up of 15.56 8.9 years, a similar proportion of donors with and without FMD were alive, and developed hypertension (22.2% versus 19.8%), proteinuria (20.6% versus 13.7%) and CVD (13.3% versus 13.5%). No donor with FMD developed an eGFR <30 mL/min/1.73 m 2 or end-stage kidney disease. The multivariable risk of mortality, CVD and renal outcomes in donors with FMD was not elevated.
Huda Saadeddin
2 years ago
Fibromuscular dysplasia (FMD) is a non-atherosclerotic arterial disease of unclear cause [1]. It is characterized by abnormal cellular proliferation and disruption of the arterial wall structure, and is manifested by dissection, aneurysm and tortuosity of many vascular beds such as the renal, carotid, visceral, external iliac arteries and even the coronary arteries [2]. The growing awareness and importance of FMD is evidenced by the recent publication of the First International Consensus on the diagnosis and management of FMD [1]. FMD is encountered in 2.0–6.6% of kidney donors during evaluation of renal vasculature [3–6]. There are limited data on how transplant centers approach donor candidates with FMD, and published transplant societies guidelines do not address this issue. Moreover, there are only a few case series that have addressed outcomes of donors with FMD.
They compared the outcomes of kidney donors with FMD to those without; after 15.5 6 8.9years of follow-up, there were no differences in mortality, cardiovascular disease, hypertension development, proteinuria or reduced kidney function between donors with and without FMD.
Donors with FMD were older (51 versus 39 years), were more likely to be women (80% versus 56%) and had a higher systolic blood pressure at donation (124.7 versus 121.3 mmHg) (P< 0.05 for all). After a mean 6 standard deviation follow-up of 15.56 8.9 years, a similar proportion of donors with and without FMD were alive, and developed hypertension (22.2% versus 19.8%), proteinuria (20.6% versus 13.7%) and CVD (13.3% versus 13.5%). No donor with FMD developed an eGFR <30 mL/min/1.73 m 2 or end-stage kidney disease. The multivariable risk of mortality, CVD and renal outcomes in donors with FMD was not elevated.
Conclusions. Kidney donors with FMD appear to do well, do not appear to incur increased risks of hypertension, proteinuria, CVD or reduced eGFR, and perhaps carefully selectedcandidates with FMD can safely donate as long as involvement of other vascular beds is ruled out.
the favorable observed long-term outcomes in kidney donors with FMD provide justification for accepting some donor candidates with FMD; and
it may also provide transplant centers with information that can be used for informed consent in accepting donor candidates with FMD provided involvement of other vascular beds is excluded and the recommended follow-up guidelines for those with FMD advocated for by FMD Registries are adhered to.
level 3
Amit Sharma
2 years ago
Please summarise this article in your own words
Fibromuscular dysplasia (FMD) can be incidentally detected (2-6.6%) in prospective donors. FMD is associated with hypertension and may cause stroke, myocardial infarction or peripheral vascular disease. There is no data/ guidelines available regarding kidney donation by FMD patients.
The study involved comparing outcomes of donors (from 1963-2007) with FMD (113 in number) with matched donors without FMD (452 in number) with respect to development of hypertension, cardiovascular disease, proteinuria and fall in GFR for a mean follow-up of 15.5±8.9 years. It was done from the dataset of RELIVE study involving 3 transplant centres in USA.
Donors with FMD were older, more women, more whites, more likely to be unrelated to their recipients, having higher systolic blood pressure and had reduced baseline eGFR.
Donors with FMD, when compared to the whole donor cohort, had increased history of first degree relative with hypertension or heart disease, increased dyslipidemia, single renal artery in non-donated kidney, less likely that left kidney was removed and laparoscopic nephrectomy was done. When compared to the matched donors without FMD, Donors with FMD had significant difference with respect to history of first degree relative with hypertension, single renal artery in non-donated kidney and less chances of removal of left kidney.
There was no difference between the 2 groups with respect to hypertension, cardiovascular disease (MI, TIA, stroke, heart failure and revascularization), ESRD development or death. Donors with FMD were more likely to develop proteinuria than the total cohort of donors (20.6% versus 13.7%), although it was similar to the matched group of donors.
The strengths of the study included being largest study with longest follow-up among donors with FMD and the outcomes were ascertainable.
The limitations of the study include lack of details regarding the extent of FMD, no details available regarding approach towards donors with FMD in the transplant programs (with chances of exclusion of donors with severe FMD), lack of data regarding focal/ multi-focal FMD, lack details regarding reconstruction of FMD vessels and lack of data regarding recipient outcomes receiving kidneys from such donors.
The study demonstrates that donors with FMD can safely donate kidneys with long-term outcomes similar to donors without FMD. Such donors should be followed-up annually for detection of hypertension and renal dysfunction.
2. What is the level of evidence provided by this article?
Level of evidence is level 3: Retrospective cohort study
Dalia Ali
2 years ago
Fibromuscular dysplasia (FMD) is a non-atherosclerotic arterial disease of unclear cause
It is characterized by abnormal cellular proliferation and disruption of the arterial wall structure, and is manifested by dissection, aneurysm and tortuosity of many vascular beds such as the renal, carotid, visceral, external iliac arteries and even the coronary arteries
After a follow-up of 4 years, none of 19 donors with grade I
(mild) or grade IV (severe) FMD lesions reported by Indudhara et al. developed hypertension or reduced glomerular filtration rate (GFR). In contrast, 26.3% ofdonors reported by Cragg et al. developed hypertension in 4.4 years.
MATERIALS AND METHODS
8922 live kidney donations at the study sites from 1963 to 2007. Family history ofhypertension, diabetes mellitus (DM), kidney disease, stroke or heart disease in donors’ first-degree relatives was recorded. Blood pressure readings were collected on multiple occasions during the donor evaluation and the average of the three lowest blood pressure measurements was used as a baseline blood pressure value. The choice of the lowest recorded readings was an attempt to avoid misclassification of donors with white coat hypertension as truly hypertensive. Hypertension at baseline and at follow-up was defined as use ofantihypertensive medications, a systolic blood pressure (SBP) >140mmHg or a diastolic blood pressure >90mmHg. The participating study sites contacted donors between 2010 and 2012 for follow-up and outcomes.
RESULTS and DISCUSSION
These results demonstrate that kidney donors who had FMD in the donated kidney at the time of kidney donation were not more likely to develop hypertension or adverse cardiovascular or renal consequences
FMD affects the renal arteries in 75% ofthe cases, 74% of the carotid arteries and 33% of the vertebral arteries
Clinically, patients with FMD present with hypertension and 35% may present with stroke or transient ischemic attack secondary to carotid and vertebral artery dissection.
Studies that have addressed outcomes of kidney donors with FMD have been small in size and had a very short follow-up
long-term recipient outcomes from FMD donors did not differ from recipients of non-FMD kidneys [8]. Two other series have shown similar results. On the other hand, there have been sporadic cases of hypertension development and renal dysfunction in some donors with FMD
Donors with FMD were less likely to have the left kidney removed. This raises three possibilities. First, FMD was present in the right kidney only and the choice was made to leave the donor with the disease-free kidney.
This is very plausible as the right renal artery is more commonly involved with FMD than the left: 33.8% versus 11.6% of unilateral FMD cases .Second, FMD was bilateral, as seen in 32–40% of FMD cases published in the literature but the left kidney was less affected
Donors with FMD were an average 12 years older than those without FMD, which is the typical profile of those with FMD, who tend to be middle-aged female, White with a family history of hypertension. Donors with FMD were more likely to be unrelated to their recipient and were more likely to be White. It is possible, therefore, that these donors were less likely to donate to recipients with a strong component ofgenetic kidney diseases, which typically present earlier in life.
strengths.
this is the largest
series of kidney donors with FMD that has been studied and with the longest follow-up. The outcomes of interest were ascertainable in the majority of donors. Nevertheless, there are limitations. The extent of FMD (unilateral versus bilateral, unifocal versus multifocal) is not captured in the dataset. In addition, there is no information about the three participating centers’ approach to donors with FMD.
Conclusion
some kidney donors with
FMD can safely donate as their long-term incidence ofmortality, CVD and hypertension, and reduced eGFR is similar to the rest of the donor population. Newly introduced recommendations regarding assessment of all vascular beds for the presence ofFMD should be strongly considered when donors with FMD are considered for kidney donation. Obviously, in recipients with multiple potential donors, the ones with FMD can perhaps be considered last. Importantly, if donor candidates with FMD are to be accepted they should be seen at least annually for early hypertension detection and signs ofkidney function decline.
level II
Heba Wagdy
2 years ago
FMD is a non-atherosclerotic systemic arterial disease of unclear etiology, detected in 2-6.6% of kidney donors during evaluation of renal vessels.
No available recommendations regarding accepting potential donors with FMD and available data on the outcome of those donors is scarce.
Studies about donors with FMD had several limitations as inclusion f small number of donors with FMD, short term follow up and absence of data about CVD post donation.
This study aimed to determine the risk of developing HTN, CVD, proteinuria and decreased eGFR in donors with FMD.
CVD is a concern in those donors as it may lead to other arterial consequences as stroke, acute MI and PAD.
The study used de-identified donor information publicly available from the RELIVE study, 113 donors with FMD discovered during donor evaluation were compared to 452 propensity score matched without FMD.
The study showed that kidney donors who had FMD in donated kidney were not at increased risk of HTN, cardiovascular or renal complications.
Donors with FMD were less likely to have left kidney removed, may be due to affection of right kidney only and leaving the donor with the disease-free kidney as FMD more commonly affect right renal artery, FMD was bilateral but the left kidney was less affected or fewer nephrectomies performed on the left due to presence of multiple arteries on the left side.
Donors with and without FMD had similar prevalence of kidney cysts and stones in the donated and non-donated kidneys.
Donors with FMD tend to be middle aged females, white with a family history of HTN and were more likely to be unrelated.
The study suggested that kidney donors with FMD can be safely accepted for donation with considering the assessment of all vascular beds for presence of FMD during the evaluation with annual follow up after donation for early detection of HTN and any decline in kidney function.
Strengths:
Among available studies, this study included the largest series of donors with FMD with the longest follow up
Outcomes of interest were ascertainable in most donors.
Limitations:
Data about extent of FMD was not available.
No information about approach to donors with FMD in the 3 centers participating in the RELIVE study
Also, whether reconstruction of FMD vessel was performed in recipient is unclear
No data about the outcome of recipients
Level 3 (Retrospective study)
Reem Younis
2 years ago
Please summarise this article in your own words
-Fibromuscular dysplasia (FMD) is a non-atherosclerotic arterial disease of unclear cause . FMD is encountered in 2.0–6.6% of kidney donors during evaluation of renal vasculature .
-The Renal and Lung Living Donor Evaluation (RELIVE) study addressed long-term outcomes of 8922 kidney donors who donated between 1963 and 2007.
-The results demonstrate that kidney donors who had FMD in the donated kidney at the time of kidney donation were not more likely to develop hypertension or adverse cardiovascular or renal consequences.
-FMD affects the renal arteries in 75% of the cases, 74% of the carotid arteries and 33% of the vertebral arteries .
-Once a FMD diagnosis is made, patients should have onetime head-to-pelvic cross-sectional vascular imaging with CT angiography. These recommendations came into existence after 2012 .
-Donors with FMD were less likely to have the left kidney removed. This raises three possibilities. First, FMD was present in the right kidney only and the choice was made to leave the donor with the disease-free kidney.
-Second, FMD was bilateral, but the left kidney was less affected. This is also plausible as even when FMD is bilateral the right kidney appears to have more significant disease . Third, it is possible that fewer left nephrectomies were performed due to the presence of multiple arteries on the left.
– Donors with FMD were an average 12 years older than those without FMD, which is the typical profile of those with FMD, who tend to be middle-aged female, White with a family history of hypertension.
-The study has strengths: it is the largest series of kidney donors with FMD that has been studied and with the longest follow-up. The outcomes of interest were ascertainable in the majority of donors.
– The limitations : The extent of FMD (unilateral versus bilateral, unifocal versus multifocal) is not captured in the dataset. In addition, there is no information about the three participating centers’ approach to donors with FMD. It is possible that the donors with FMD who were included in the analysis had mild disease, since perhaps individuals with severe disease were not allowed to donate.
Lastly, they do not have data on the outcomes of the recipients of the donated kidney.
-In all, these data demonstrate that some kidney donors with FMD can safely donate as their long-term incidence of mortality, CVD and hypertension, and reduced eGFR is similar to the rest of the donor population. Newly introduced recommendations regarding assessment of all vascular beds for the presence
of FMD should be strongly considered when donors with FMD are considered for kidney donation. Obviously, in recipients with multiple potential donors, the ones with FMD can perhaps be considered last. Importantly, if donor candidates with FMD are to be accepted they should be seen at least annually for early hypertension detection and signs of kidney function decline. What is the level of evidence provided by this article?
Level 2
Ghalia sawaf
2 years ago
Methods
8922 donors from 1962 to 2007
Follow up each of CVD- BP- proteinuria- eGFR
113 donors with FMD discovered during evaluation
452 propensity score matched donors without FMD
Kaplan’s statistics
Results
Donors with FMD was older – 80% women-
SBP was higher and eGFR was lower at donation than non FMD donor
Open nephrectomy, right kidney donation were significantly higher in donors with FMD
After a mean follow-up of 15.568.9 years
There were no differences in the distribution of cause of death between the two groups.
Regarding CVD incidence were similar between donors with and without FMD.
developed hypertension (22.2% versus 19.8%)
Donors with FMD were more likely to develop proteinuria(20.6versus13.7%)(P¼0.04) ;however, there were no differences in outcomes
study has strengths
this is the largest series of kidney donors with FMD with the longest follow-up.
limitations.
The extent of FMD is not captured in the dataset.
It is possible that the donors with FMD who were included in the analysis had mild disease, since perhaps individuals with severe disease were not allowed to donate.
No data on the outcomes of the recipients of the donated kidney.
Leve III
Mohammad Alshaikh
2 years ago
Please summarise this article in your own words
Fibromascular dysplasia is non atherosclerotic arterial disease due to abnormal endothilial cell proliferation disease causing arterial wall aneurysms and disruption manifested by dissection tortuosity of vascular beds, it affects the renal arteries in 75% of the cases, 74% of the carotid arteries and 33% of the vertebral arteries. 2-6.6% of kideny donors found to have fibromascular dysplasia.
Study design: 8922 kidney donors from 1963-2007, were collected from RELIVE study, in three centers, 113 donors with FMD, compared with 452 with no fibromuscular dysplasia, were enrolled 1:4 ratio, with a mean follow up of 15.5+/-8.9 years. The family history for HTN, DM, kidney disease, stroke, or heart disease in all donors was reported. B/P >140/90 mmHg considered as hypertension ESKD was defined by need for dialysis, or receiving or being listed for a kidney transplant. CVD defined defined by any myocardial infarction, congestive heart failure, transient ischemic attack, stroke, or need for coronary or peripheral arterial intervention. Proteinuria defined as one or more of the following: urine protein by dipstick >+2, urine protein/osmolality >0.42 ratio, urine random protein >15 mg/dL or 24-h protein >300 mg/day.
Results: = Donors with FMD were older (51 versus 39 years), and were more likely to be women (80% versus 56%) and White (90.3% versus 84.7%) (P< 0.05). = Baseline eGFR was also lower in donors with FMD (79 versus 88 mL/ min/1.73 m2), (P < 0.001). = Right kidney donation were significantly higher in donors with FMD,having one artery = CVD, diabetes development, proteinuria status, and eGFR, Cause of death were comparable in both study group. = Donors with FMD, compared to donors without FMD, were more likely to develop proteinuria (P= 0.04). = Non of those with FMD experienced decrease eGFR<30ml/min/1.73m2, or ESKD. = Donors with FMD had a single renal artery in the non-donated kidney in 78.8% of cases compared with 61.6% of donors without FMD(P = 0.01).
Strength of the study: Largest series of kidney donors with FMD that has been studied and with the longest follow-up. The outcomes of interest were collected in all donors.
Limitations of the study: The extent of FMD (unilateral/ bilateral, unifocal/ multifocal) is not captured in the dataset. No information about the three participating centers’approach to donors with FMD. No data on the outcomes of the recipients of the donated kidney.
Conclusion: Kidney donors with FMD can safely donate as their long-term incidence of mortality, CVD and hypertension, and reduced eGFR is similar to the rest of the donor population. Patients with diagnosis of FMD should have onetime head-to-pelvic cross-sectional vascular imaging with CT angiography, when considered as donors, and should be followed annually for early detection of hypertension, and sign of kidney function decline.
What is the level of evidence provided by this article? Level of evidence III – retrospective cohort
ISAAC BUSAYO ABIOLA
2 years ago
SUMMARY
Introduction
Fibromuscular dysplasia (FMD) is non atherosclerotic vascular disease commoner among women and characterized with excessive growth and proliferation of arteria wall anatomy. It can affect the vessels of the kidney, brain, heart, GIT and carotid vessels. Many of the available guidelines do not provide enough evidence on the use of the kidney from individuals with FMD despite the incidence of 2.0% – 6.6 % among potential donors during work up
Aim/goal
to evaluate the cardiovascular outcome in donor with FMD compared to those without
Materials and methods
data from renal and living lung Donor Evaluation (RELIVE) was obtained from 1963 to 2007 was obtained
out of total of 8922, donors in the study, 113 were found to have FMD and 8809 without FMD
donors’ demographic data and other required information were obtained via mail or telephone and some from their recipients between 2010 to 2012
case and control were matched in the ratio 1: 4
factors like hypertension, proteinuria, different degree of GFR, and development of CVD were compared between donors with FMD and those without
all the analysis were done with the aid of Stata version 16.1
Result
donors with FMD have characteristic like been older, more women, and white
there was not statistically significant different of occurrence of CVD events between donors with FMD and those without
donors with FMD were more likely to developed proteinuria after mean follow up year of 15.5_+ 8.9 years, but this was absent in the propensity analysis even including hypertension or ESRD
the multivariable risk of mortality for hypertension, CVD, and reduced GFR among the donors with FMD is the same.
Conclusion
This study has shown that donors with FMD were not at a higher risk for CVD event, hypertension or any renal abnormality outcome compared to those with FMD. Similarly, following 16 years of follow up, it was found that donors with FMD had similar blood pressure and protein excretion as those donors without FMD.
Level of evidence is 3, retrospective observational
amiri elaf
2 years ago
# Please summarise this article in your own words
# The objective:
To study the development of HTN, CVD, proteinuria and reduced e-GFR in a large cohort of kidney donors with FMD.
# Introduction:
*Fibromuscular dysplasia (FMD) is a non-atherosclerotic arterial disease of unknown etiology, in which there is abnormal cellular proliferation and disruption of the arterial wall structure presented by dissection, aneurysm and tortuosity of many vascular beds such as the renal, carotid, visceral, external iliac arteries and even the coronary arteries
*FMD is encountered in 2.0–6.6% of kidney donors during evaluation of renal vasculature.
*There are limited data on how transplant centers approach donor with FMD and only few case that showed the outcomes, in addition to that, the published transplant society’s guidelines do not conducted recommendation.
# Material and methods:
The (RELIVE) study was a National Institutes of Health-sponsored effort that studied donor outcomes from the University of Minnesota, Mayo Clinic–Rochester and the University of Alabama–Birmingham.
*There were 8922 live kidney donations at the study sites from 1963 to 2007.
* Family history of HTN, DM, kidney disease, stroke or heart disease in donors’ first-degree relatives was recorded.
*BP readings were collected on multiple occasions during the donor evaluation with using the average.
*Donors filled out quality of life surveys, health questionnaires regarding the development of CVD. HTN, hypertension,DM, RFT and other conditions.
*Laboratory data and records from their private physicians.
# Results:
* Donors with FMD were older and were more likely to be women and White.
* Baseline eGFR was also lower in donors with FMD.
*Open nephrectomy, right kidney donation and likelihood of the remaining kidney having just one artery were significantly higher in donors with FMD.
*The two groups were highly comparable except for a having family history of HTN, undergoing open nephrectomy, right kidney removal and having a singular artery in the non donated kidneys in donors with FMD.
*Vital status was ascertainable in 99.8% of donors, CVD (90.2%), proteinuria (89.9%), and e GFR ( 97.1%.).
*Cause of death was available for roughly 50% of all donors, and there were no differences in the distribution of cause of death between the two groups.
*MI, stroke, TIAs, HF and need for coronary revascularization were similar between donors with and without FMD.
*After a mean follow-up of 15.568.9 years, 13.5% of donors without FMD developed CVD, 19.8% developed hypertension, 13.7% developed proteinuria and 0.6% developed ESKD. *The corresponding proportions in donors with FMD were 13.3, 22.2 and 20.6%, and none developed Egfr <30mL/min/1.73m2 or ESKD.
* Donors with FMD, compared with the entire donor cohort without FMD, were more likely to develop proteinuria.
*The strengths of the study are that, largest series of kidney donors with FMD that has been studied and with the longest follow-up and the outcomes of interest were ascertainable in the majority of donors.
*The limitations of the study are that, the extent of FMD is not captured in the dataset.
No information about the three participating centers’ approach to donors with FMD.
It is also not clear whether reconstruction of the FMD vessel was performed in the
recipient.
No data on the outcomes of the recipients of the donated kidney.
*Newly introduced recommendations regarding assessment of all vascular beds for the presence of FMD should be strongly considered when donors with FMD are considered for kidney donation.
# Conclusion:
Kidney donors with FMD appear to do well and do not appear to incur increased risks of HTN, CVD or reduced eGFR.
Carefully selected candidates with FMD may be able to donate a kidney safely.
# What is the level of evidence provided by this article?
*It is retrospective cohort study level 3.
Long-term outcomes of kidney donors with fibromuscular dysplasia
Summary
This is a retrospective study in the Renal and Lung Living Donor Evaluation (RELIVE) in USA, addressed long-term outcomes of 8922 kidney donors who donated between 1963 and 2007. The study compared the development of hypertension, cardiovascular disease (CVD), proteinuria and reduced estimated glomerular filtration rate (eGFR) in 113 kidney donors with FMD discovered during donor evaluation versus 452 propensity score matched donors without FMD
MATERIALS AND METHODS:
The study populations: participants kidney donors from RELIVE study from 3 US transplant centers, who donated between 1963 and 2007.
113 kidney donors with FMD compared with 452 propensity score matched donors without FMD, matching (4 controls : 1 case) for long the development of HTN, CVD, proteinuria and reduced eGFR rate
The participating study sites contacted donors between 2010and 2012 for follow-up and outcomes,which defined as:
CVD:any of the following: MI , CHF, TIA, stroke, or need for coronary or peripheral arterial intervention (angioplasty, stenting or bypass).
ESKD: need for dialysis, or receiving or being listed for a kidney transplant.
HTN: as use of antihypertensive medications, SBP>=140mmHg or a DBP>=90mmHg.
Proteinuria: as one or more of the following: urine protein by dipstick 2., urine protein/osmolality
>0.42 ratio, urine random protein >15mg/dL or 24-h protein >300mg/day.
Exclusion: any donors with proteinuria, measured GFR or creatinine clearance <80mL/min.
Result
-Were 8922 live kidney donations at the three centers between 1963 and 2007 .
Donors with FMD were older (51 versus 39 years).
Donor were more likely to be women (80% versus 56%). and White (90.3% versus 84.7%) .
Baseline eGFR was also lower in donors with FMD (79 versus 88 mL/min/1.73 m2
Open nephrectomy, right kidney donation and likelihood of the remaining kidney having just one artery were higher in donors with FMD.
The survival was similar in both FMD and non-FMD donors.
Hypertension was insignificantly higher in FMD donors than non-FMD donors ( 22.2 versus 19.8%)
Cardiovascular disease was almost equal in both groups of donors ( 13.3 versus 13.5 %)
Proteinuria was slightly higher in FMD donors than non-FMD donors ( 20.6 versus 13.7%)
None of FMD donors developed ESRD or GFR less than 30 ml/min.
Strengths of the study :
Large sample size
Limitations :
Extent of FMD not captured in the dataset – thus mild disease donors have been included while severe FMD candidates have not been allowed to donate, thus allowing opportunity for skewing of results.
Missing distinction between focal and multifocal FMD.
Conclusion:
Donor with FMD can be included in donation as there is no increase in the risk of proteinuria .hypertension ,cardiovascular disease and chronic kidney disease after donation if selected well.
Donors with FMD should have follow up of blood pressure and assessment of kidney functions at least once per years.
What is the level of evidence provided by this article
Thank you, in addition, no date regarding the outcome in the recipients.
KAMAL ELGORASHI
2 years ago
Introduction :
Fibromuscular dysplasia (FMD) is a non-atherosclerotic arterial disease, of no clear cause. Charecteristic:
Abnormal cellular proliferation, and disruption of the arterial wall structure.
Dissection, aneurysm, and tortuosity of vascular bed, such as renal, carotid, visceral, EIA, and even coronary arteries.
FMD is encountered in 2.0-6.6% of KD during evaluation of donor vasculature, but yet no published guidelines in dealing with FMD. Material and methods:
RELIVE study of donor donors outcome, 8922 live donors from 1963 to 2007, with recorded family history of hypertension, DM, kidney disease, stroke or heart disease, in the first degree relative.
Blood pressure multiple readings collected, during donor eveluation, used the average lowest 3 BP readings as base line.
Hypertension defined as use of AHM, SBP>/140 mmHg, DBP >/90 mmHg.
Study sites contacting participant between 2010-2012, they filled out questionnaire about development of heart disease, kidney disease, DM, and hypertension.
Post donation events also recorded, and information also recorded from recipients.
CVD was defined by ( MI, CHF, TIA, stroke, or need for any vascular intervention).
ESKD need as need for dialysis, or conducting transplantation.
Protienuria defined as one of the following, (dipstick >2+, urine protein/osmolality >0.42 ratio, urine random protein>15mg/dL or 24-h protein >300 mg/D.
All donor selected between centers are highly comparable, with exclusion of any donor with proteinuria, mGFR<80 ml/min.
most agreed the presence of one or more focal lesion to establish diagnosis of FMD.
Statistical Analysis:
Donor with FMD or without FMD were determined by Chi-square or Fishers exact test, for categorical variables and Kruskal-Wallis test for continuous variables.
HTN, proteinuria, eGFR < 60 ml/min, <45 ml/min, < 30 ml/min, and CVD were compared between donor with FMD vs those without FMD.
Score matching use a ratio of 1:4 and matched age /year, sex, ethnicity, and year of donation.
Results:
Donor with FMD was older 51 vs 39 years.
Women was more than male (80% vs56%).
White was (90.3% vs 84.7%)
Baseline eGFR was lower in donors with FMD, (79 vs 88 ml/min)
right kidney nephrectomy likely having one artery were higher in donor with FMD.
No difference in the cause of death between tow group.
CVD incidence was (MI, stroke, TIA, HF, and need of coronary revascularization was similar between 2 donor with FMD and those was not.
After mean follow up of 15.5+/-8.9 years, (13.5% of donor without FMD developed CVD vs 13.3% with FMD), (19.8% developed HTN in donor without FMD vs 22.2% in donor with FMD), (13.7% developed protienuria in donor without FMD vs 20.6% in donor with FMD), and (0.65 developed ESKD in donor without FMD vs 0.0% in donor with FMD).
Donor with FMD are more likely to develop proteinuria 20.6% vs 13.7%.
Discussion:
Donors with FMD at the time of donation were not more likely develop HTN, CVD, or renal disease.
Recommended CT angiography one time head to pelvis, for all donor diagnosed with FMD.
Study was short in time follow-up and small in size .
Data from Myo Clinic of 2250 donors , 38 had FMD, 14 of them having bilateral disease. After 16.6 years of follow-up, donors with FMD had similar BP, and uPCR, compared with donors without FMD.
Recipients with kidney from FMD donor after long term follow-up, foud had no difference from recipient with kidney from donors with no FMD in outcome.
sporadic cases with HTN and renal failure were noticed in some donors with FMD.
donor with FMD were less likely to have left kidney nephrectomy; this raise three possibilities, First; FMD was present in right kidney only. Second; FMD was bilateral , but the left kidney was less affected. Third; fewer left kidney nephrectomies done due to multiple renal artery supply to the left kidney.
Long-term outcomes of kidney donors with fibromuscular dysplasia Summary
This is a retrospective study in the Renal and Lung Living Donor Evaluation (RELIVE) in USA, addressed long-term outcomes of 8922 kidney donors who donated between 1963 and 2007. The study compared the development of hypertension, cardiovascular disease (CVD), proteinuria and reduced estimated glomerular filtration rate (eGFR) in 113 kidney donors with FMD discovered during donor evaluation versus 452 propensity score matched donors without FMD. Study’s results and outcome
Kidney donors with FMD appear to do well, do not appear to incur increased risks of hypertension, proteinuria, CVD or reduced eGFR.
Limitations of the study
a) Small number of donors with FMD studied.
b) Short-term follow-up.
c) The extent of FMD (unilateral versus bilateral, unifocal versus multifocal) is not captured in the dataset.
d) There is no information about the three participating centers’ approach to donors with FMD.
e) It is not clear whether reconstruction of the FMD vessel was performed in the recipient.
f) No data on the outcomes of the recipients of the donated kidney.
g) The lack of outcomes data on major cardiovascular events after donation.
strengths of the study
a) It is the largest series of kidney donors with FMD that has been studied and with the longest follow-up.
b) The outcomes of interest were ascertainable in the majority of donors. The level of evidence provided by this article:
This is a retrospective cohort study
Level of evidence grade 3.
FMD is encountered in 2.0–6.6% of kidney donors during evaluation of renal vasculature. Current guidelines
do not provide recommendations regarding the use of kidneys from donors with FMD and there is a paucity of data on the outcomes of these donors.
MATERIALS AND METHODS:
The study populations: participants kidney donors from RELIVE study from 3 US transplant centers, who donated between 1963 and 2007.
113 kidney donors with FMD compared with 452 propensity score matched donors without FMD, matching (4 controls : 1 case) for long the development of HTN, CVD, proteinuria and reduced eGFR rate
The participating study sites contacted donors between 2010and 2012 for follow-up and outcomes,which defined as: CVD:any of the following: MI , CHF, TIA, stroke, or need for coronary or peripheral arterial intervention (angioplasty, stenting or bypass). ESKD: need for dialysis, or receiving or being listed for a kidney transplant. HTN: as use of antihypertensive medications, SBP>=140mmHg or a DBP>=90mmHg. Proteinuria: as one or more of the following: urine protein by dipstick 2., urine protein/osmolality
>0.42 ratio, urine random protein >15mg/dL or 24-h protein >300mg/day. Exclusion: any donors with proteinuria, measured GFR or creatinine clearance <80mL/min.
Results:
Donors with FMD were older, were more likely to be women and had a higher systolic blood pressure at donation (124.7 versus 121.3mmHg) (P<0.05 for all).
Higher likelihood of having family history of hypertension, undergoing open nephrectomy, right kidney removal and having a singular artery in the nondonated kidneys in donors with FMD.
The mean follow-up of 15.5 years.
After follow-up similar proportion of donors with and without FMD were alive, and developed hypertension (22.2% versus 19.8%), proteinuria (20.6% versus 13.7%) and CVD (13.3% versus 13.5%).
No donor with FMD developed an eGFR <30mL/min/1.73 m2 or end-stage kidney disease.
The multivariable risk of mortality, CVD and renal outcomes in donors with FMD was not elevated.
Limitations:
– The extent of FMD (unilateral vs bilateral, unifocal vs multifocal) is not captured in the dataset
– Approach of the centers to donors with FMD was not mentioned, disease severity, other vessels involvement.
– It is also not clear whether reconstruction of the FMD vessel was performed in the recipient.
– The outcomes of the recipients was not available.
Conclusions. Kidney donors with FMD appear to do well, do not appear to incur increased risks of hypertension, proteinuria, CVD or reduced eGFR, and perhaps carefully selected candidates with FMD can safely donate as long as involvement of other vascular beds is ruled out.
Level of evidence:
Level 3, retrospective cohort study
♧ Introduction: ▪︎Fibromuscular dysplasia (FMD) is a non-atherosclerotic arterial disease of unclear cause. FMD is encountered in 2.0–6.6% of kidney donors during evaluation of renal vasculature. ▪︎There are limited data on how transplant centers approach donor candidates with FMD, and published transplant societies guidelines do not address this issue. ▪︎This analysis has studied the development of HTN, CVD, proteinuria and reduced eGFR in a large cohort of kidney donors with FMD. ▪︎The goal of this analysis was to ascertain CVD outcomes since FMD is not an abnormality that is confined to the renal arteries in the majority of cases, and can lead to serious arterial consequences such as stroke, acute MI and PAD. ♧Methods:
▪︎The RELIVE study addressed long-term outcomes of 8922 kidney donors who donated between 1963 and 2007.
▪︎This study compared the development of HTN, CVD, proteinuria and reduced eGFR in 113 kidney donors with FMD discovered during donor evaluation vs 452 propensity score matched donors without FMD. ▪︎Outcomes modeling with logistic and Cox regression analysis and Kaplan–Meier statistics were performed. ♧ Results:
▪︎Donors with FMD were older (51 vs 39yrs), were more likely to be women (80% vs 56%) and had a higher systolic blood pressure at donation (124.7 vs 121.3 mmHg) (P< 0.05 for all).
▪︎After a mean 6 standard deviation follow-up of 15.5 6 8.9 years, a similar proportion of donors with and without FMD were alive, and developed HTN (22.2% vs 19.8%), proteinuria (20.6% vs 13.7%) and CVD (13.3% vs 13.5%). No donor with FMD developed an eGFR <30 mL/min/1.73 m2 or ESRD.
▪︎The multivariable risk of mortality, CVD and renal outcomes in donors with FMD was not elevated. ♧Strengths of the study: 1. Largest series of kidney donors with FMD that has been studied and with the longest follow-up. 2. The outcomes of interest were ascertainable in the majority of donors. ♧Limitations: 1. The extent of FMD (unilateral versus bilateral, unifocal versus multifocal) is not captured in the dataset. 2. There is no information about the three participating centers’ approach to donors with FMD. 3. Perhaps individuals with severe disease were not allowed to donate so they are not included in this study. 4. The distinction between focal and multifocal FMD, while missing from the dataset, is perhaps not highly relevant. 5. It is also not clear whether reconstruction of the FMD vessel was performed in the recipient. 6. There is no data on the outcomes of the recipients of the donated kidney. ♧Conclusions: ▪︎The result of this study data demonstrated that some kidney donors with FMD can safely donate as their long-term incidence of mortality, CVD, HTN, and reduced eGFR is similar to the rest of the donor population. ▪︎Newly introduced recommendations regarding assessment of all vascular beds for the presence of FMD should be strongly considered when donors with FMD are considered for kidney donation. ▪︎In recipients with multiple potential donors, the ones with FMD can perhaps be considered last. ▪︎If donor candidates with FMD are to be accepted they should be seen at least annually for early HTN detection and signs of kidney function decline.
Fibromuscular dysplasia (FMD) is a non-atherosclerotic arterial disease of unclear cause .
It is characterized by abnormal cellular proliferation and disruption of the arterial wall structure, and is manifested by dissection, aneurysm and tortuosity of many vascular beds such as the renal, carotid, visceral, external iliac arteries and even the coronary arteries .
The Renal and Lung Living Donor Evaluation (RELIVE) study addressed longterm outcomes of 8922 kidney donors who donated between 1963 and 2007. to compare the development of hypertension, cardiovascular disease (CVD), proteinuria and reduced estimated glomerular filtration rate (eGFR) in 113 kidney donors with FMD discovered during donor evaluation versus 452 propensity score matched donors without FMD .
Study revealed
Donors with FMD were older (51 versus 39 years), and were more likely to be women (80% versus 56%) and White (90.3% versus 84.7%) (P < 0.05 for all) .
Baseline eGFR was also lower in donors with FMD (79 versus 88 mL/ min/1.73 m2, P < 0.001) .
Open nephrectomy, right kidney do- nation and likelihood of the remaining kidney having just one artery were significantly higher in donors with FMD .
CVD development was ascertainable in 98%, diabetes development in 90.2%, urinary protein assessment and proteinuria status in 89.9%, and eGFR values in 97.1%. Cause of death was available for roughly 50% of all donors .
After a mean follow-up of 15.5 6 8.9 years, 13.5% of donors without FMD developed CVD, 19.8% developed hypertension, 13.7% developed proteinuria and 0.6% developed ESKD .
Donors with FMD were less likely to have the left kidney re- moved. This raises three possibilities. First, FMD was present in the right kidney only and the choice was made to leave the do- nor with the disease-free kidney .
What is the level of evidence provided by this article?
LEVEL OF EVIDENCE COHOHORT RETEROSEPECTIVE STUDY 3
Last edited 2 years ago by MOHAMMED GAFAR medi913911@gmail.com
Summary:
Aim of the study:
to ascertain cardiovascular outcomes in donors with FMD.
Methods:
data from RELIVE study ( 113 kidney donors with FMD discovered during donor evaluation versus 452 propensity score matched donors without FMD).
To compare the development of hypertension, cardiovascular disease, proteinuria and reduced estimated glomerular filtration rate in kidney donors with FMD to donors without FMD.
Results.
Donors with FMD were older, more likely to be women and had higher systolic blood pressure at donation.
After a mean +- standard deviation follow-up of 15.5 +- 8.9 years, a similar proportion of donors with and without FMD were alive and developed hypertension (22.2% versus 19.8%), proteinuria (20.6% versus 13.7%) and CVD (13.3% versus 13.5%).
No donor with FMD developed an eGFR <30 mL/min/1.73 m2 or end-stage kidney disease.
The multivariable risk of mortality, CVD and renal outcomes in donors with FMD was not elevated.
Conclusion:
Kidney donors with FMD appear to do well, do not appear to incur increased risks of hypertension, proteinuria, CVD or reduced eGFR, and perhaps carefully selected candidates with FMD can safely donate as long as the involvement of other vascular beds is ruled out.
Strength:
this is the largest series of kidney donors with FMD that has been studied and with the longest follow-up.
The outcomes were ascertainable in the majority of donors.
Limitations:
. The extent of FMD (unilateral versus bilateral, unifocal versus multifocal) is not captured in the dataset.
there is no information about the three participating centers’ approach to donors with FMD.
It is also not clear whether the reconstruction of the FMD vessel was performed in the recipient.
no data on the outcomes of the recipients of the donated kidney.
What is the level of evidence provided by this article?
● FMD is encountered in 2.0–6.6% of kidney donors during evaluation of renal vasculature
● fibromuscular dysplasia (FMD) of the renal artery is associated with hypertension and involves many vascular beds resulting in stroke, myocardial infarction and peripheral arterial disease
● Study includes 3 centers in USA
● Renal and Lung Living Donor Evaluation (RELIVE) study addressed long-term outcomes of 8922 kidney donors who donated between 1963 and 2007
● Donors with FMD compared to donors without FMD
● Outcomes : hypertension, (CVD), proteinuria and reduced eGFR
● Follow up 15.5 6 8.9 years
● Result : there were no differences in mortality, cardiovascular disease, hypertension development, proteinuria or reduced kidney function between donors with and without FMD.
● Conclusion : Kidney donors with FMD appear to do well, do not appear to incur increased risks of hypertension, proteinuria, CVD or reduced eGFR, and perhaps carefully selected candidates with FMD can safely donate as long as involvement of other vascular beds is ruled out.
● The strength of study :
** It is the largest series of kidney donors with FMD that has been studied and with the longest follow-up.
** The outcomes of interest were ascertainable in the majority of donors.
● Limitations :
** The extent of FMD (unilateral versus bilateral, unifocal versus multifocal) is not captured in the dataset.
** There is no information about the three participating centers’ approach to donors with FMD
** The distinction between focal and multifocal FMD, while missing from the dataset, is perhaps not highly relevant as collectively the available evidence suggests that these are two distinct entities rather than multifocal FMD being a result of progressive focal FMD
** It is not clear whether reconstruction of the FMD vessel was performed in the recipient.
** There is no data on the outcomes of the
recipients of the donated kidney.
● The impact this study on practice
◇ the favorable observed long-term outcomes in kidney donors with FMD provide justification for accepting some donor candidates with FMD
◇ it provide transplant centers with information that can be used for informed consent in accepting donor candidates with FMD provided involvement of other vascular beds is excluded and the recommended follow-up guidelines for those with FMD advocated for by FMD Registries are adhered to.
IV. Long-term outcomes of kidney donors with fibromuscular dysplasia (FMD) Please summarise this article in your own words Introduction
FMD of the renal artery is associated with HTN & involves many vascular beds (carotid, visceral, external iliac arteries & coronary arteries).
It is a non-atherosclerotic arterial disease of unclear cause.
FMD can result in stroke, MI & PAD.
FMD is seen in 2.0–6.6% of kidney donors.
Data on how transplant centers deal with potential donors with FMD are sparse, & only a few case series have addressed outcomes of donors with FMD.
Indudhara et al (19 donors with FMD, followed for 4 years): none developed HTN or reduced GFR.
Cragg et al: 26.3% of donors developed HTN in 4.4 years.
A recent study of 38 donors with FMD reported similar BP & UACR compared to those with no FMD over >10 years of follow -up. The study Aim
To study the development of HTN, CVD, proteinuria & reduced eGFR in a large cohort of kidney donors with FMD. Methods RELIVE study: a National Institutes of Health -sponsored effort that studied donor outcomes from the U of M, Mayo Clinic–Rochester & U of Alabama–Birmingham. Population: 8922 LKDs from 1963 to 2007. FH of HTN, DM, kidney disease, stroke or heart disease in donors’ 1st-degree relatives was recorded. BP readings on multiple occasions & the average of the 3 lowest BP readings were used as a baseline BP value; the lowest readings use was to avoid misclassification of donors with white coat HTN as truly hypertensive. HTN was defined as use of medications, a SBP =/>140mmHg or a DBP =/> 90mmHg. Donors filled out QOL surveys, health questionnaires regarding the development of heart disease, HTN, DM, kidney function & other conditions. Laboratory data & records from their private physicians were provided. CVD defined by any of the following: MI CHF TIA Stroke Need for arterial intervention (angioplasty, stenting or bypass). ESKD defined by need for dialysis, or receiving or being listed for a kidney TX. Proteinuria defined as 1 or more of the following: Urine protein by dipstick =/>2 Urine protein/osmolality >0.42 ratio Urine random protein >15mg/Dl 24-h protein >300mg/day. How FMD was defined & how the candidacy of donors with FMD defined are not specified in the RELIVE dataset. Statistics Frequencies & proportions used for categorical variables & median & IQR for continuous variables. Chi-square or Fisher’s exact tests for categorical variables. Kruskal–Wallis test for continuous variables. HTN, proteinuria, eGFR <60mL/min, <45mL/ min & <30mL/min, & CVD development were compared in donors with FMD (case) vs those without FMD (control). Propensity score matching: ratio of 1:4(1 case per 4 controls). Kaplan–Meier method used to estimate cumulative incidence for outcomes. Logistic regression and Adjusted risks for the outcomes of interest estimated by Cox proportional-hazards modeling. All the analyses were performed on Stata version 16.1. P-value of <0.05 considered significant. Results
Donors with FMD were older (51 vs 39), & more likely to be women (80% vs 56%) & White (90.3% vs 84.7%) (P<0.05 for all). Baseline eGFR was also lower in donors with FMD (79 vs 88mL/min, P<0.001).
Open nephrectomy, RK right donation & likelihood of the remaining kidney having just one artery were higher in donors with FMD.
The 2 groups were highly comparable except for a higher likelihood of having FH of HTN, open nephrectomy, RK removal & having a singular artery in the non-donated kidneys in donors with FMD.
Vital status ascertainable in 99.8% of donors, CVD development in 98%, DM in 90.2%, urinary protein assessment & proteinuria status in 89.9%, & eGFR values in 97.1% of donors.
Cause of death available for 50% of donors. No differences in distribution of cause of death between the 2 groups. CVD incidence: MI, stroke, TIAs, HF & need for coronary revascularization were similar between donors with & without FMD.
After a mean follow-up of 15.5+/-8.9 years: 13.5% of donorswithout FMD developed CVD, 19.8% HTN, 13.7% proteinuria & 0.6% ESKD; corresponding rates in donors with FMD were 13.3, 22.2 & 20.6%, and none developed eGFR <30mL/min or ESKD. Donors with FMD vs without FMD, were more likely to develop proteinuria (20.6 vs 13.7%) (P=0.04).
However, in the propensity matched analysis, no difference between the groups on any outcome, including proteinuria. Multivariable risk of CV, HTN & reduced eGFR
Risk of mortality in donors with FMD was
0.64 (P=0.61) & of CVD was 1.04 (P=0.95). Risks of HTN, proteinuria, eGFR <60mL/min & eGFR <45mL/min were not elevated. Discussion Kidney donors who had FMD in the donated kidney were not more likely to develop HTN or adverse CV or renal diseases. FMD may present with HTN & 35% may present with stroke or TIA secondary to carotid & vertebral artery dissection. Once FMD diagnosis is made, onetime head-to-pelvic vascular imaging with CT angiography is indicated. Studies addressing outcomes of donors with FMD were small in size & short in follow-up. Mayo Clinic data: out of 2250 donors, 38 had FMD & bilateral disease seen in 14 of these. After 16.6 years of follow-up, donors with FMD had similar BP & UP excretion to in donors without FMD; long-term recipient outcomes from FMD donors did not differ from that of non-FMD kidneys. Donors with FMD were less likely to have the left kidney removed. Donors with FMD had a single renal artery in the non-donated kidney in 78.8% of cases compared with 61.6% of donors without FMD (P=0.01) & 90% of kidneys donated by both groups had a single renal artery. Donors with FMD older (an average 12yrs) than those without FMD; typically those with FMD tend to be middle-aged White female with a FH of HTN. Donors with FMD more likely unrelated to recipients & more likely to be White. Strengths It is the largest series of kidney donors with FMD that has been studied & the longest follow-up. Outcomes were ascertainable in the majority of donors. Limitations The extent of FMD (unilateral vs bilateral, unifocal vs multifocal) is not captured in the dataset. No information about the centers’ approach to donors with FMD. Possibly donors with FMD included in the analysis had mild disease; perhaps those with severe disease not allowed to donate. No data on the outcomes of the recipients of the donated kidney. ==================== What is the level of evidence provided by this article? Level III
Introduction
This was an observational case control study looking at Kidney donors with Fibromuscular Dysplasia and compared to donors without fibromuscular dysplasia (FMD).
FMD is defines as a non-atherosclerotic disease of the arteries whose etiology is unknown. It can affect multiple vascular beds including renal, carotid, iliac, visceral and coronary. It commonly presents with hypertension and can also present with stroke if the carotids are affected. FMD is encountered in 2.0-6.6% of kidney donors during evaluation of renal vasculature. There is limited data as to how a transplant center should approach a potential kidney donor with FMD
Methodology
Data was obtained from the RELIVE study that studied donor outcomes from 3 centers. They collected data for donors who had donated a kidney from the time period of 1963-2007.
A total of 8922 donors had donated a kidney from 1963-2007 out of which 113 had FMD and 8809 had no FMD. It was not clear how the 3 centers had selected the donors with FMD.
Donors with FMD were compared to propensity score matched donors with no FMD in a ratio of 1:4.
The participating study sites contacted the donors between 2010 and 2012.
The main outcomes were the development of:
Hypertension
Proteinuria
CKD
Cardiovascular disease
Results
The donors were followed up for a mean period of 15.5 years.
Donors with FMD were more likely to be older (51 yrs vs 39 yrs), more likely to be women (80% vs 56%) and more likely to be Caucasian (90.3% vs 84.7%)
Baseline eGFR was also lower in donors with FMD (79 vs 88 mld/min/1.73m2. p < 0.001).
13.3% of donors with FMD developed CVD compared to 13.5% of donors without FMD
22.2% of donors with FMD developed HTN compared to 19.8% of donors without FMD.
No donor with FMD developed ESKD or GFR < 30 mls/min/1.73m2 compared to 0.6% of donors without FMD who developed ESKD
20.6% of donors with FMD developed proteinuria compared to 13.7% of donors without FMD (p=0.04)
However, in the propensity score matched analysis, there was no difference between the two groups on any of the outcomes studied including proteinuria.
These results demonstrate that kidney donors with FMD were not more likely to develop HTN or adverse CV or kidney outcomes.
Studies looking at outcomes of donors with FMD are sparse. One study from the Mayo Clinic looked at 38 kidney donors with FMD. After 16.6 years of follow up, donors with FMD had similar BPs and urine protein excretion compared to those observed in donors without FMD. Even the long term outcomes of kidney recipients with kidneys from donors with FMD did not differ from those who received kidneys from donors without FMD
Study Limitations:
The extent of FMD (unilateral vs bilateral, univocal vs multifocal) was not captured in the dataset
No information regarding the 3 centers’ approach to donors with FMD is provided
Conclusion
Carefully selected kidney donors with FMD can safely donate.
Assessment of all vascular beds for the presence of FMD should be strongly considered when donors with FMD are considered for donation.
If donors with FMD are accepted for kidney donation, they should be evaluated at least annually for early detection of hypertension and signs of kidney function decline
Level OF Evidence
This is a case control study so the level of evidence is 3
– Fibromuscular dysplasia (FMD) is a non-atherosclerotic arterial disease of unclear cause.
– It is characterized by abnormal cellular proliferation and disruption of the arterial wall structure, and is manifested by dissection, aneurysm and tortuosity of many vascular beds such as the renal, carotid, visceral, external iliac arteries and even the coronary arteries.
– FMD is encountered in 2.0–6.6% of kidney donors during evaluation of renal vasculature.
– There are limited data on how transplant canters approach donor candidates with FMD, and published transplant societies guidelines do not address this issue. Moreover, there are only a few case series that have addressed outcomes of donors with FMD.
– This is an observational retrospective cohort study comparing the development of HTN, CVD outcomes, proteinuria & GFR decline in donors with FMD & donors without FMD using The Renal and Lung Living Donor Evaluation (RELIVE) study which addressed long-term outcomes of 8922 kidney donors who donated between 1963 and 2007.
– It concluded that donors with FMD appear to do well with no increase in HTN, CVD, proteinuria or decline in GFR in comparison to non FMD donors, also that perhaps carefully selected donors with FMD can safely donate as long as affection of other vasculature beds are ruled out .
Level of evidence :
– Level 3 , observational retrospective cohort study
Fibromuscular dysplasia (FMD) is a nonatherosclerotic systemic arterial disease that is discovered during kidney donor evaluation in 2.0–6.6%
This study compared the development of hypertension, cardiovascular disease (CVD), proteinuria and reduced estimated glomerular filtration rate (eGFR) in 113 kidney donors with FMD discovered during donor evaluation versus 452 propensity score matched donors without FMD.
Results
– Donors with FMD were older (51 versus 39 years), were more likely to be women (80% versus 56%)
– Donors with FMD had a higher systolic blood pressure at donation (124.7 versus 121.3 mmHg).
– After a mean follow-up of 15.5 6 8.9 years, a similar proportion of donors with and without FMD were alive, and developed hypertension (22.2% versus 19.8%), proteinuria (20.6% versus 13.7%) and CVD (13.3% versus 13.5%).
– No donor with FMD developed an eGFR < 30 mL/min/1.73 m2 or end-stage kidney disease.
These results demonstrate that kidney donors who had FMD in the donated kidney at the time of kidney donation were not at higher risk to develop hypertension or adverse cardiovascular or renal consequences. It is important to mention that recipients of FMD kidney were not at risk too of developing more renal complications.
This is a retrospective cohort study with level of evidence III
Fibromuscular dysplasia (FMD) is a non-atherosclerotic arterial
disease with disruption of the arterial wall structure leading to dissection, aneurysm and tortuosity of many visceral arteries.
it is encountered in 2-6.6% of kidney donors
Material and method:
The Renal and Lung Living Donor Evaluation (RELIVE) study evaluated 8922 kidney donors from 1963–2007 duration.
The parameters evaluated were hypertension, CVD, decrease in eGFR and mortality.
There was follow-up of around 14.5 to 15.5 years
Results There were 113 donors with FMS vs 8809 donors without FMD. Donors with FMD were older, female and white donors. Baseline eGFR was lower in donors with FMD
Open nephrectomy, right kidney donation and likelihood of the remaining kidney having just one artery were significantly higher in donors with FMD.
at follow-up, the incidence of hypertension, proteinuria, CVD and incidence of ESRD was similar in both the groups
Conclusion
Kidney donors with FMD can safely donate as their long-term incidence of mortality, CVD and hypertension, and reduced eGFR is similar to the rest of the donor population.
All vascular beds should be assessed prior to kidney donation in FMD donors
Donor candidates with FMD should be seen at least annually for early hypertension detection and signs of kidney function decline.
Yes sir, I would accept donor with FMD after screening all vascular beds.
I would counsel the donor about strict post-donation follow-up for hypertension and renal function.
Thank you, do not forget to counsel the recipient as well.
Mohammed Abdallah
2 years ago
Please summarise this article in your own words
Introduction
FMD is a non-atherosclerotic arterial disease. It is characterized by abnormal cellular proliferation and disruption of the arterial wall structure, and is manifested by dissection, aneurysm and tortuosity of many vascular beds such as the renal, carotid, visceral, external iliac arteries and even the coronary arteries
Outcome of FMD was addressed by a few studies. Most studies were small size with short duration of follow-up and the results were inconclusive
Aim of the study: study the outcome of HTN, CVD, proteinuria and reduced eGFR in kidney donors with FMD
Material and Methods
RELIVE study addressed the outcome of 8922 live kidney donors (1963to 2007). They compared the risk of HTN, CVD, proteinuria and low GFR in donors with FMD (n= 113) with matched donors with no FMD (n=425). The ratio was 1:4. Duration of follow-up was 14.5 (± 9.5) years for kidney donors with FMD and 15.5 (± 8.9) years for matched donors without FMD
Results
Donors with FMD were older, mostly women and with low Baseline eGFR
After a mean follow-up of 15.568.9years, 13.5% of donors without FMD developed CVD, 19.8% developed HTN, 13.7% developed proteinuria and 0.6% developed ESKD. The corresponding proportions in donors with FMD were 13.3, 22.2 and 20.6%, and none developed eGFR <30mL/min or ESKD
Discussion
FMD affects the renal arteries (75%), carotid arteries (74%) and vertebral arteries (33%). Clinically, patients with FMD present with HTN and 35% may present with stroke or TIA secondary to carotid and vertebral artery dissection. These observations have led to the recommendation that once a FMD diagnosis is made, patients should have one-time head-to-pelvic cross-sectional vascular imaging with CT angiography
Data from Mayo Clinic, from 2250 donors who presented for donation, 38 had FMD and in whom bilateral disease was encountered in 14. After 16.6years of follow-up, donors with FMD had similar blood pressure and urinary protein excretion to those observed in donors without FMD
Strengths and Limitations: the strength was large size kidney donors. Limitations were
1.. Extent of FMD (unilateral versus bilateral, unifocal versus multifocal) is not captured in the dataset
2. There is no information about the approach to donors with FMD (donors included possible were mild disease and severe disease excluded)
Conclusion
No increase risk of HTN, CVD, proteinuria or redued eGFR in donors with FMD when compared with matched donor without FMD. This may provide a justification for kidney donation in selected cases with FMD. Assessment of all vascular beds for the presence of FMD should be strongly considered when donors with FMD are considered for kidney donation
What is the level of evidence provided by this article?
Fibromuscular dysplasia (FMD) accounts for about 2.0–6.6% of kidney donors .It is is manifested by dissection, aneurysm and tortuosity of many vascular beds such as the renal, carotid, visceral, external iliac arteries and even the coronary arteries .This study compares the outcomes of HTN, CVD, proteinuria & GFR decline in donors with FMD versus donors without FMD.8922 kidney donors were being recruited and followed up for 15.5 6 8.9 years.
RESULTS:FMD do not increase the risk of hypertension ,CVD or GFR decline in donors but patient have to be thoroughly investigated for extra renal involvement of vascular beds as that is a contraindication.
Major limitation of the study included that the extent of the FMD ,and whether reconstructive surgery done or not and also the outcome of recipient not mentioned in the study.
At our center, donors with FMD not considered for donation.
What is the level of evidence provided by this article?
Level of evidence 3 (retrospective cohort study).
This is an observational cohort study with level 3 evidence to compared the development of hypertension, cardiovascular disease (CVD), proteinuria and reduced estimated glomerular filtration rate (eGFR) in among kidney donors with FMD. There were 8922 live kidney donations at the three centers between 1963 and 2007 of which 113 donors had FMD. Donors with FMD were older (51 versus 39 years), were more likely to be women (80% versus 56%) and had a higher systolic blood pressure at donation (124.7 versus 121.3 mmHg) (P< 0.05 for all). After a mean 6 standard deviation follow-up of 15.5 6 8.9 years, a similar proportion of donors with and without FMD were alive, and developed hypertension (22.2% versus 19.8%), proteinuria (20.6% versus 13.7%) and CVD (13.3% versus 13.5%). No donor with FMD developed an eGFR <30 mL/min/1.73 m2 or end-stage kidney disease. The multivariable risk of mortality, CVD and renal outcomes in donors with FMD was not elevated. Strengths include largest series of kidney donors with FMD that has been studied and with the longest follow-up. The limitations include the extent of FMD (unilateral versus bilateral, unifocal versus multifocal) is not captured in the dataset. In addition, there is no information about the three participating centers’ approach to donors with FMD. In conclusion, kidney donors with FMD appear to do well, do not appear to incur increased risks of hypertension, proteinuria, CVD or reduced eGFR.
Ø Study conducted in 3 centres in USA addressed long-term outcomes of 8922 kidney donors who donated between 1963 and 2007
Ø Compared the development of hypertension, cardiovascular disease (CVD), proteinuria and reduced estimated glomerular filtration rate (eGFR) in 113 kidney donors with FMD discovered during donor evaluation versus 452 propensity score matched donors without FMD
Ø Donors with FMD had a higher systolic blood pressure at donation (124.7 versus 121.3 mmHg) (P< 0.05 for all). After a mean 6 standard deviation follow-up of 15.5 6 8.9 years, a similar proportion of donors with and without FMD were alive, and developed hypertension (22.2% versus 19.8%), proteinuria (20.6% versus 13.7%) and CVD (13.3% versus 13.5%).
Ø No donor with FMD developed an eGFR <30 mL/min/1.73 m2 or end-stage kidney disease.
Ø The multivariable risk of mortality, CVD and renal outcomes in donors with FMD was not elevated
Ø Donor with FMD appear to do well, do not appear to incur increased risks of hypertension, proteinuria, CVD or reduced eGFR.
Level 3
The Renal and Lung Living Donor Evaluation (RELIVE) study involved 8922 living renal donors from 1963 to 2007, included 8922 living renal donors from 1963 and 2007 were assorted as FMD (113) and without FMD (8809). Donors with FMD were found to be older (51 against 39 years), mostly women (80% vs 56%) and White (90.3% vs 84.7%) with significant p value (P<0.05 for all).
Baseline eGFR was even detected lower in donors with FMD in comparison to non-FMD (79 versus 88mL/min/1.73m2, P<0.001).
Incidence of associated family history of hypertension was higher, besides open nephrectomy for right kidney with single arterial supply compared to non-donated kidneys in donors with FMD.
Mean follow-up of 15.568.9 years and donors without FMD developed CVD by 13.5%, 19.8% hypertension, 13.7% proteinuria and 0.6% ESKD in comparison to donors with
FMD have never developed eGFR<30mL/min/1.73m2 or ESKD except more prone to develop proteinuria (20.6 versus 13.7%) (P=0.04).
The estimated risk of mortality in donors with FMD was 0.64 (0.11, 3.65) (P=0.61), whereas CVD was 1.04 (0.36, 2.97) (P=0.95).
Risks of hypertension or proteinuria or eGFR decline <60mL/min/1.73m2 were not significant.
Donors with FMD were less likely to develop CVD or HTN or proteinuria or renal impairment. FMD clinically involved the renal arteries in 75%, 74% of the carotid arteries and 33% of the vertebral arteries in these cases.
Patients with FMD can be complicated by hypertension or even 35% develop stroke or transient ischemic attack because of carotid and vertebral artery dissection. Study suggested the necessity to perform onetime head-to-pelvic cross-sectional vascular imaging with CT angiography.
Study conducted by the Mayo Clinic including 2250 donors; 38 had FMD with concurrent bilateral disease in only 14 cases. Follow up after 16.6 years of donors with FMD demonstrated that similar blood pressure and urinary protein excretion to those in donors without FMD. The long-term recipient outcomes from FMD donors did not differ from recipients of non-FMD kidneys according to their study.
The incidence of involvement of the right renal artery is greater than the left 33.8% vs 11.6% of unilateral FMD cases. There were no associated differences in the prevalence of kidney cysts or stones in the donated and non-donated kidneys in both groups.
Strengths
largest series of kidney donors with FMD with the longest follow-up
Limitations
sub classification of FMD either unilateral or bilateral and unifocal or multifocal
Data concerning the reconstruction of the FMD vessel was ever performed in the recipient was deficient.
Kidney donors with FMD can still safely donate as their long-term incidence of mortality, CVD and hypertension, and reduced eGFR is similar to the general donor population. Candidate donors with FMD should be monitored annually for detection of hypertension and renal functions decline.
What is the level of evidence provided by this article?
Level of evidence: III.
The Renal and Lung Living Donor Evaluation (RELIVE) study addressed long-term outcomes of 8922 kidney donorswhodonatedbetween1963and2007.Wecomparedthe development of hypertension, cardiovascular disease (CVD), proteinuria and reduced estimated glomerular filtration rate (eGFR) in 113 kidney donors with FMD discovered during donor evaluation versus 452 propensity score matched donors without FMD. Outcomes modeling with logistic and Cox regression analysis and Kaplan–Meier statistics were performed. Results. Donors with FMD were older (51 versus 39years), were more likely to be women (80% versus 56%) and had a higher systolic blood pressure at donation (124.7 versus 121.3mmHg)(P<0.05forall).Afteramean6standarddeviation follow-up of 15.568.9years, a similar proportion of donorswithandwithoutFMDwerealive,anddevelopedhypertension (22.2% versus 19.8%),proteinuria(20.6% versus13.7%) and CVD (13.3% versus 13.5%). No donor with FMD developed an eGFR <30mL/min/1.73 m2 or end-stage kidney disease. The multivariable risk of mortality, CVD and renal outcomesindonorswithFMDwasnotelevated. Conclusions. Kidney donors with FMD appear to do well, do notappeartoincurincreasedrisksofhypertension,proteinuria, CVD or reduced eGFR, and perhaps carefully select
There were 8922 live kidney donations at the three centers between 1963 and 2007 (Figure 1). The characteristics of donors with FMD (n¼113) and those without FMD (n¼8809) are presented in Table 1. Donors with FMD were older (51 versus 39years), and were more likely to be women (80% versus 56%) and White (90.3% versus 84.7%) (P<0.05 for all). Baseline eGFR was also lower in donors with FMD (79 versus 88mL/ min/1.73m2,P<0.001). Open nephrectomy, right kidney donation and likelihood of the remaining kidney having just one artery were significantly higher in donors with FMD. In the propensity score matched comparison the two groups were highlycomparableexceptforahigherlikelihoodofhavingfamily history of hypertension, undergoing open nephrectomy,
right kidney removal and having a singular artery in the nondonatedkidneysindonorswithFMD(Table2). Vitalstatuswasascertainablein99.8% ofdonorsasof2010– 12.CVDdevelopmentwasascertainablein98%,diabetesdevelopment in 90.2%, urinary protein assessment and proteinuria status in 89.9%, and eGFR values in 97.1%. Cause of death was availableforroughly 50% ofalldonors. Therewerenodifferencesinthedistribution ofcause of death betweenthetwo groups (data not shown). Regarding CVD incidence: myocardial infarction, stroke, transient ischemic attacks, heart failure and need for coronary revascularization were similar between donorswithandwithoutFMD. After a mean follow-up of 15.568.9years, 13.5% of donors without FMD developed CVD, 19.8% developed hypertension, 13.7% developed proteinuria and 0.6% developed ESKD (Table 3A). The corresponding proportions in donors with FMD were 13.3, 22.2 and 20.6%, and none developed eGFR <30mL/min/1.73m2 or ESKD. Donors with FMD, compared with the entire donor cohort without FMD, were more likely to develop proteinuria (20.6 versus 13.7%) (P¼0.04). In the propensity matched score analysis; however, there were no differences between the two donor groups on any of the outcomes studied,includingproteinuria(Table3B).The cumulativemortality incidence, CVD, hypertension, proteinuria, and eGFR <60 and <45mL/min/1.73m2 are provided in Table 4. Figure 2 depicts the Kaplan–Meier estimates of the different outcomesThe multivariable risk of mortality in donors withFMD was 0.64 (0.11, 3.65) (P¼0.61) and that of CVD was 1.04 (0.36, 2.97) (P¼0.95). Similarly, the risks of hypertension, proteinuria, eGFR <60mL/min/1.73m2 and eGFR <45mL/min/ 1.73m2 werenotelevated,either(Table5).Theresultsfromthe
logistic and Cox regression models were highly concordant for alloutcomes.
level of evidence II
Long-term outcomes of kidney donors with fibromuscular dysplasia
Fibromuscular dysplasia (FMD) is a non-atherosclerotic arterial disease of unclear cause. It due to abnormal cellular proliferation and disruption of the arterial wall structure, and manifested by dissection, aneurysm and tortuosity of many vascular beds. FMD is encountered in 2.0–6.6%
of kidney donors during evaluation of renal vasculature. There are only few case series that address the outcome of donors with FMD, resulting in stroke, myocardial infarction and peripheral arterial disease.
Aim:
studied the development of hypertension, cardiovascular disease (CVD), proteinuria and reduced estimated GFR (eGFR) in a large cohort of kidney donors with FMD.
Methods.
The Renal and Lung Living Donor Evaluation (RELIVE) study addressed long-term outcomes of 8922 kidney donors who donated between 1963 and 2007. We compared the development of hypertension, cardiovascular disease (CVD), proteinuria and reduced estimated glomerular filtration rate (eGFR) in 113 kidney donors with FMD discovered during donor evaluation versus 452 propensity score matched donors without FMD. Outcomes modeling with logistic and Cox regression analysis and Kaplan–Meier statistics were performed.
Results:
FMD donors are more likely to be women, had high blood pressure at donation. After a mean follow-up of 15.5 ± 8.9 years, similar proportion of donors with and without FMD were alive, and developed hypertension, proteinuria and CVD.
No donor with FMD developed an e GFR < 30 ml/min/1.73m2. or ESRD.
DISCUSSION
kidney donors who had FMD in the donated kidney at the time of kidney donation were not more likely to develop hypertension or adverse cardiovascular or renal consequences. FMD affects renal arteries in 75%, the carotid arteries in 74% and 33% of the vertebral arteries. Patient with FMD present with hypertension and stroke or TIA secondary to carotid and vertebral artery dissection. These observations have led to the recommendation that once a FMD diagnosis is made, patients should have one-time head-to-pelvic cross-section vascular imaging with CT angiography, this recommendation exist since 2012. Moreover, long-term recipient outcomes from FMD donors did not differ from recipients of non-FMD kidneys.
Strength of the study:
1- Largest study
2- The outcomes of interest were ascertainable in the majority of donors.
Limitations:
The extent of FMD is not determined in the dataset.
It is possible that the donors with FMD who were included in the analysis had mild disease.
They suspect that if these donors had FMD involving the visceral arterial bed or the iliac arteries they would have been excluded, as these regions are included in the routine angiographic imaging of kidney donors.
No data about the recipient from FMD donor.
Conclusion:
In all, these data demonstrate that some kidney donors with FMD can safely donate as their long-term incidence of mortality, CVD and hypertension, and reduced eGFR is similar to the rest of the donor population.
Recommendation regarding assessment of all vascular beds for the presence of FMD should be strongly considered in donors with FMD.
Recipient with multiple donors, FMD donor should be considered last and the kidney with mild disease is chosen.
if donor candidates with FMD are to be accepted they should be seen at least annually for early hypertension detection and signs of kidney function decline.
It is the largest series of donor with FMD. FMD is a non-atherosclerotic arterial disease of medium arteries that is due to abnormal proliferation of arterial wall structure.
It was seen in 2.0 – 6.6% of renal donors.
Its a retrospective study done to evaluate the development of hypertension, proteinuria, CVD, and diminished GFR in donors with FMD.
After follow up of 15 years ,no difference was found in mortality, CVD, hypertension, proteinuria, decreased GFR between donors with and with out FMD.
I t was concluded that some donors with FMD can donate safely, after exclusion of extrarenal vessel involvement, as 35% of patient with FMD can develop stroke/TIA. FMD donors should be monitored at least annually for hypertension.
Study has level of evidence III.
Please summarize this article in your own words
This is a retrospective study where data was collected from the RELIVE study (Renal and Lung Living Donor Evaluation) which studied the long-term outcomes of 8922 Kidney donors between 1963-2007. DATA from 3 transplant centers.
113 kidney donors with FMD were found during evaluation of donors who developed HTN, CVD, proteinuria and dropped GFR.
These donors were evaluated against 452 score matched donors without FMD.
FMD was more common in older, female donors with pre-donation high systolic BP.
Donors with FMD were followed for 15 years, they were found to have more hypertension, proteinuria and CVD.
None of these donors developed GFR below 30 ml/min/m2 or ESRD.
Limitations:
1- The extent of FMD was not studied including unilateral vs bilateral or multifocal vs unifocal.
2- Missing data about the participating centers and their data about donors with FMD.
3- No clear data about reconstruction of FMD vessel in the recipients.
4- No data about the recipients’ outcomes.
What is the level of evidence provided by this article?
Level of evidence III
Introduction
Fibromuscular dysplasia (FMD) is caused by abnormal cellular proliferation and disruption of the arterial wall structure, which can be complicated by dissection, aneurysm and tortuosity of variable vascular beds mainly renal, carotid, visceral, external iliac arteries up to coronary arteries.
FMD was discovered to be of 2.0–6.6% incidence during routine assessment for renal donation. Other previous studies had small number of FMD donors with short period follow up regarding the development of complications as cardiovascular disease or hypertension or renal function decline and renal impairment in the form of proteinuria.
Materials and methods
The Renal and Lung Living Donor Evaluation (RELIVE) study involved 8922 living renal donors from 1963 to 2007. CVD included the occurrence of myocardial infarction, congestive heart failure, transient ischemic attack, stroke, or need for coronary or peripheral arterial intervention (angioplasty, stenting or bypass). Proteinuria detected by dipstick exceeded 2 +, urine protein/osmolality >0.42 ratio, urine random protein >15mg/dL or 24-h protein >300mg/day is considered.
At time of donation, donors were medically free regarding proteinuria or renal impairment. Establishment of FMD diagnosis was accepted on the presence of at least one focal or multifocal arterial lesion.
Statistical analysis
Hypertension, proteinuria, eGFR <60mL/min/1.73 m2, <45mL/min/1.73 m2 and <30mL/min/1.73 m2, and CVD development were compared in donors with FMD (case) to donors without FMD (control).
P-value of <0.05 was considered statistically significant.
Results
The included 8922 living renal donors from 1963 and 2007 were assorted as FMD (113) and without FMD (8809). Donors with FMD were found to be older (51 against 39 years), mostly women (80% vs 56%) and White (90.3% vs 84.7%) with significant p value (P<0.05 for all).
Baseline eGFR was even detected lower in donors with FMD (79 versus 88mL/min/1.73m2, P<0.001).
According to this study, the incidence of associated family history of hypertension was higher, besides open nephrectomy for right kidney with single arterial supply compared to non-donated kidneys in donors with FMD.
Data revealed that after a mean follow-up of 15.568.9 years, about donors without FMD developed CVD by 13.5%, 19.8% hypertension, 13.7% proteinuria and 0.6% ESKD.
While donors with FMD have never developed eGFR<30mL/min/1.73m2 or ESKD. However, they were more prone to develop proteinuria (20.6 versus 13.7%) (P=0.04).
The estimated risk of mortality in donors with FMD was 0.64 (0.11, 3.65) (P=0.61), whereas CVD was 1.04 (0.36, 2.97) (P=0.95). Interestingly, the risks of hypertension or proteinuria or eGFR decline <60mL/min/1.73m2 were not significant.
Discussion
According to this study, donors with FMD were less likely to develop CVD or HTN or proteinuria or renal impairment. FMD clinically involved the renal arteries in 75%, 74% of the carotid arteries and 33% of the vertebral arteries in these cases. Patients with FMD can be complicated by hypertension or even 35% develop stroke or transient ischemic attack as a consequence of carotid and vertebral artery dissection. This fact suggested the necessity to perform onetime head-to-pelvic cross-sectional vascular imaging with CT angiography.
An informative study conducted by the Mayo Clinic including 2250 donors; 38 had FMD with concurrent bilateral disease in only 14 cases. Follow up after 16.6 years of donors with FMD demonstrated that similar blood pressure and urinary protein excretion to those in donors without FMD. The long-term recipient outcomes from FMD donors did not differ from recipients of non-FMD kidneys according to their study.
The incidence of involvement of the right renal artery is greater than the left 33.8% vs 11.6% of unilateral FMD cases. There were no associated differences in the prevalence of kidney cysts or stones in the donated and non-donated kidneys in both groups.
Strengths of this project is being the largest series of kidney donors with FMD with the longest follow-up. Limitations were mainly the sub classification of FMD either unilateral or bilateral and unifocal or multifocal. Data concerning the reconstruction of the FMD vessel was ever performed in the recipient was deficient.
They concluded that, kidney donors with FMD can still safely donate as their long-term incidence of mortality, CVD and hypertension, and reduced eGFR is similar to the general donor population. Candidate donors with FMD should be monitored annually for detection of hypertension and renal functions decline.
Level of evidence: III.
Introduction:
Fibromuscular dysplasia (FMD)is non-atherosclerotic arterial disease due to abnormal endothelial cell proliferation disease causing arterial wall aneurysms and disruption manifested by dissection tortuosity of vascular beds.
It affects the renal arteries in 75% of the cases, 74% of the carotid arteries and 33% of the vertebral arteries.
FMD is found in 2-6.6% of kidney donors .
This is a retrospective study that included participants from the Renal and Lung Living Donors (RELIVE).It included 8922 kidney donors between 1963 and 2007. The study compared the development of hypertension, CVD, proteinuria and reduced estimated glomerular filtration rate (eGFR) in 113 kidney donors with FMD discovered during donor evaluation versus 452 matched donors without FMD.
Outcome
Kidney donors with FMD have no increased risks of hypertension, proteinuria, CVD or reduced eGFR.
Limitations:
The extent of FMD is not captured in the dataset and the centers approach to donors with FMD, disease severity, other vessels involvement was not mentioned.
The outcomes of the recipients was not available and it is also not clear whether reconstruction of the FMD vessel was performed in the recipient.
Level of evidence:
Level 3, retrospective cohort study
This is the largest ever series of donor with FMD that has been studied. FMD is a non-atherosclerotic arterial disease of medium vessels that is secondary to abnormal proliferation of arterial wall structure.
It was seen in 2.0 to 6.6% of renal donors.
Its a retrospective study conducted to evaluate the development of hypertension, proteinuria, CVD, and reduced GFR in donors with FMD.
After follow up of 15+_ years there was no differences in mortality, CVD, Hypertension, proteinuria, decreased GFR between donors with and with out FMD.
According to data concluded that some donors with FMD can donate safely, after exclusion extrarenal vessel involvement, because 35% of patient with FMD can develop stroke/TIA. FMD donors should be followed at least annually for hypertension.
Level of evidence III.
The aim o the study ;
———————————
Was to study the development of hypertension, cardiovascular disease (CVD), proteinuria and reduced estimated GFR (eGFR) in kidney donors with FMD.
The type o the study ;
————————————
Retrospective cohort study .
Ethical approval;
—————————-
This study was exempt from Institutional Review Board approval as it used de-identified donor information that is publicly available.
Population ;
——————
1-The study group;113 kidney donors with FMD discovered during donor evaluation .
2-Controlled group; 452 propensity score matched donors without FMD.
Results;
———————-
After 15.5 +_ 8.9 years of follow-up, there were no differences in mortality, cardiovascular disease, hypertension development, proteinuria or reduced kidney function between donors with and without FMD.
The strengths of the study;
————————————-
It is the largest series of kidney donors with FMD that has been studied and with the longest follow-up.
The limitations;
————————————
1-The extent of FMD (unilateral versus bilateral, unifocal versus multifocal) is not captured in the data set.
2- There is no information about the three participating centers’ approach to donors with FMD.
Conclusion;
—————————–
1-These data demonstrate that some kidney donors with FMD can safely donate as their long-term incidence of mortality, CVD and hypertension, and reduced eGFR is similar to the rest of the donor population.
2-Newly introduced recommendations regarding assessment of all vascular beds for the presence of FMD should be strongly considered when donors with FMD are considered for kidney donation.
3- In recipients with multiple potential donors, the ones with FMD can perhaps be considered last. Importantly, if donor candidates with FMD are to be accepted they should be seen at least annually for early hypertension detection and signs of kidney function decline.
What is the level of evidence provided by this article?
————————————————————————
Level 11I
▪︎Introduction
Fibromuscular dysplasia (FMD) is a non-atherosclerotic arterial disease .
it causes abnormal cellular proliferation and disruption of the arterial wall structure.
It affect many vascular beds such as the renal, carotid, visceral, external iliac arteries and even the coronary arteries .
It usually manifests wigh stroke, hypertension, or myocardial infarction.
FMD is encountered in 2.0–6.6% of kidney donors during evaluation of renal vasculature.
Method
The study was conducted to evaluated the development of hypertension, CVD, proteinuria and reduced eGFR in donors with FMD.
retrospective cohort study included 9822 living donors
dara collected from RELIVE from 1963 to 2007 .
113 kidney donors with FMD discovered during donor evaluation versus 452 propensity score matched donors without FMD.
On follow up for 15.5 6 8.9 years,
The study compared donors with FMD with non-FMD donors with main baseline characteristics of age, sex, eGFR
▪︎Results
,-Donors with FMD were older (51 versus 39) years, mostly were women(80%).
FMD donors had higher systolic BP and had lower baseline eGFR 79 versus 88 mL/ min/1.73 m2
the outcomes of kidney donors with FMD compared to those without ,there were no differences in mortality, cardiovascular disease, hypertension, proteinuria or reduced kidney function between donors with and without FMD.
▪︎strengths of the study
-largest number of kidney donors with FMD that has been studied .
– the longest follow-up.
▪︎limitations of the study
– The extent of FMD (unilateral versus bilateral, uni-focal versus multifocal) is not determined
– there is no information about the three participating centers.
-It is possible that the donors with FMD who were included in the analysis had mild disease, since perhaps individuals with severe disease were not allowed to donate.
-Not clear whether reconstruction of the FMD vessel was performed in the recipient.
– no data on the outcomes of the recipients of the donated kidney.
▪︎conclusion
FMD can safely donate their kidneys after the exclusion of extrarenal vascular beds involvements.
FMD can safely donate as their long-term incidence of mortality, CVD and hypertension, and reduced eGFR is similar to the rest of the donor population
recommendations regarding assessment of all vascular beds for the presence of FMD should be strongly considered when donors with FMD are considered for kidney donation.
FMD donors should be seen at least annually for early hypertension detection and signs of kidney function decline.
INTRODUCTION
· fibromuscular dysplasia (FMD) of the renal artery is associated with hypertension and involves many vascular beds resulting in stroke, myocardial infarction and peripheral arterial disease
· FMD can be found in 2.0–6.6% of kidney donors during evaluation of renal vasculature
· Aim of the study: a comparison of the outcomes of kidney donors with FMD to those without
MATERIALS AND METHODS
· Study included 3 centers in USA
· Renal and Lung Living Donor Evaluation (RELIVE) Study, involved 8922 live kidney donations
from 1963 to 2007 with follow up data 2010-2012
· Donors with FMD compared to those without FMD
· Outcomes: cardiovascular disease, HTN, and reduced GFR
· Definitions:
– CVD: myocardial infarction, congestive heart failure, transient ischemic attack, stroke, or need
for coronary or peripheral arterial intervention
-End-stage kidney disease (ESKD): the need for dialysis, or receiving or being listed for a kidney
transplant.
-Proteinuria: urine protein by dipstick 2+, urine protein/osmolality >0.42 ratio, urine random
protein >15 mg/dL or 24-h protein >300 mg/day
· Exclusion criteria:
1- donors with proteinuria,
2- measured GFR or creatinine clearance <80 mL/min
RESULTS
· Donors with FMD were older, and were more likely to be women and White.
· Baseline eGFR was lower in donors with FMD
· Open nephrectomy, right kidney donation and likelihood of the remaining kidney having just one artery were significantly higher in donors with FMD.
· There were no differences in the distribution of cause of death between the two groups
· CVD incidence was the same between donors with and without FMD
DISCUSSION
· kidney donors with FMD in the donated kidney at the time of kidney donation, didn’t develop hypertension or adverse cardiovascular or renal consequences
· patients with FMD present with HTN and 35% may present with stroke or TIA secondary to carotid and vertebral artery dissection
· Donors with FMD were less likely to donate the left kidney
· Strength of the study: large number of donors and long follow up.
· Limitations:
1-The extent of FMD is not captured in the dataset.
2-there is no information about the three participating centers’ approach to donors with FMD.
3-It is possible that the donors with FMD who were included in the analysis had mild disease, since perhaps individuals with severe disease were not allowed to donate
4- donors with FMD involving the visceral arterial bed or the iliac arteries could have been excluded
5- It is not clear whether reconstruction of the FMD vessel was performed in the recipient.
6-There are no available data on the outcomes of the recipients of the donated kidney
CONCLUSION
· Kidney donors with FMD are doing well, and have no increased risk of HTN, CVD, or reduced GFR.
· Candidates with FMD can donate their kidney safely, if they were selected carefully
What is the level of evidence provided by this article?
Retrospective study level 3
Background
Fibromuscular dysplasia (FMD) of the renal arteries is considered one of the causes of renovascular hypertension, it’s categorized by abnormal cellular proliferation and alteration of the arterial wall structure and can exist with dissection, aneurysm, and tortuosity of many vascular beds in the kidneys, carotids, visceral, external iliac vessels and coronaries lead to stroke, hypertension, heart attacks and peripheral vascular diseases it can be found in smaller numbers of potential kidney donors with uncertain consequences on long-term outcomes.
Aim of the study
To assess the outcome of donations from people with known FMD in terms of reduced e GFR, CVD, proteinuria, and hypertension
Method
A retrospective observational cohort study from 3 centers in the USA data collected from RELIVE from the period of 1963-2007 and FU data from 2010-2012, a total of > 9822 living donors included in this study and compared donors with FMD with non-FMD donors with main baseline characteristics of age, sex, e GFR with target outcome of CVD, HTN, proteinuria, and ESRD. Median follow-up period 15.5+/- 8.9 years.
Results
FMD was found in 113 of the FMD donors with a mean age of 51 years older than the no FMD donors (452) with a mean age of 39, the majority (80%vs 56%) of FMD donors were females with higher systolic BP at donation time lower baseline e GFR 79ml/min/1.73 m2
But upon the follow-up period, both have similar survival rates and similar rates of hypertension and CVD, and no donor with FMD develops advanced CKD including ESKD. Even with multivariable risk adjustment for mortality, CVD, and ESKD.
Discussion
This observational cohort study confirms the safety of donation from isolated renal FMD candidates with no significant long-term impact on the donor and also the recipient in terms of risk of HTN, proteinuria, CVD, or progressive reduction in e GFR. which is similar to the finding from previous few studies including case series and small sample size with short FU period, however, few cases report it dose address the higher rate of Hypertension in FMD donors.
Conclusion
FMD kidney donors on long-term FU doing well without increased risk of HTN, proteinuria, CVD, and ESKD, with the vigilant selection still donors with FMD can safely donate their kidneys after the exclusion of extrarenal vascular beds involvements.
Strength of this study
Large cohort with good sample size and a long follow-up period and the outcome of interest was discoverable in the majority of donors
Limitations of this study
Missing data about the FMD details focal vs multifocal, unilateral, or bilateral
No clear exclusion criteria from the 3 participating centers about the severity of FMD in their donors.
Missing data about the recipient’s outcome
What is the level of evidence provided by this article?
level 3 retrospective cohort study
1. Please summarise this article in your own words
Introduction
Fibromuscular dysplasia (FMD) is a non-atherosclerotic arterial disease of unclear cause.
In FMD there is abnormal cellular growth with leading to arterial wall disruption which is appears as disruption of the arterial wall structure, and is manifested by dissection, aneurysm and tortuosity of many vascular beds such as the renal, carotid, visceral, external iliac arteries and even the coronary arteries. It is found to be in 2-6.6% of kidney donors.
Methods.
The Renal and Lung Living Donor Evaluation (RELIVE) study studied long-term outcomes of 8922 donors between 1963 and 2007. We compared the development of hypertension, cardiovascular disease (CVD), proteinuria and reduced estimated glomerular filtration rate (eGFR) in 113 kidney donors with FMD discovered during donor evaluation versus 452 propensity score matched donors without FMD.
Results
Age of donors with FMD (51 versus 39 years), they were more likely to be women (80% versus 56%) and had a higher systolic blood pressure at donation (124.7 versus 121.3mmHg) (P<0.05 for all).
After follow-up of 15.5 years, a similar proportion of
donors with and without FMD were alive, and developed hypertension
(22.2% versus 19.8%), proteinuria (20.6% versus 13.7%)
and CVD (13.3% versus 13.5%). No donor with FMD developed
an eGFR <30mL/min/1.73 m2 or end-stage kidney disease.
Conclusion:
Donor kidneys with FMD can be transplanted safely if involvement of other vascular bed is ruled out.
What is level of evidence?
Level 111
Fibromuscular dysplasia (FMD) is not uncommon in prospective kidney donors but long term outcomes are not very clear. It is being postulated that there could be association of FMD with hypertension and /or vascular diseases.
Currently, there are no guidelines regarding recommendations on use of kidneys from donors with FMD.
METHODS
This study used data from the RELIEVE study. No separate case -controls recruitment was done in the study. 113 kidney donors with FMD were selected as cases and 452 controls were selected who were propensity score matched donors.
RESULTS
LIMITATIONS
STRENGTHS
CONCLUSION
Overall the study concluded that kidney donors with FMD can safely donate kidneys and their long term outcomes of cardiovascular events and falling eGFR is no different from those without FMD
Level of evidence 3
Please summarise this article in your own words.
Fibromuscular dysplasia FMD is an important entity in which there is non atherosclerotic arterial disease characterized by abnormal cell proliferation and arterial wall damage . It can present as torturous vessels, aneurysms and dissections. The awareness about FMD comes from First international Consensus on FMD. Incidence varies from 2-6% in kidney donors and approach is variable among transplant centres.
Current guidelines do not give clear directions about donation with FMD and there is paucity of data. This study evaluated the effect of kidney donation with FMD .
The Renal and Lung Living Donor evaluation RELIEVE evaluated the outcome of donation with FMD
Total donors- 8922
From 1963-2007
Those with FMD- 114 vs 452 Propensity matched donors.
Donors with FMD were mostly White females and 12 year older. Blood pressure was higher in donors with FMD
They found that there was no increases risk of hypertension, CKD/ESRD and Cardiovascular disease in FMD group as compared to controls.
Conclusion-
Kidney donation with the presence of FMD do well and do not increase the risks of hypertension, CVD, Proteinuria or low GFR in selected cases. Safe kidney donation is possible as long as other vascular trees are carefully assessed.
Post donation a follow up for blood pressure and renal functions is mandatory
What is the level of evidence provided by this article?
Retrospective Cohort study Level 111
This article is large cohort study done in 3 centres between 1963 to 2007; address outcome of fibromuscular dysplasia in kidney donor.
Fibromuscular dysplasia is non atherosclerotic systemic arterial disease of unknown causes.
FMD is renal artery stenosis may complicated to hypertension and proteinuria and decrease eGFR.
It’s consequences may progress to myocardial infarction and stroke and peripheral vascular disease.
It’s characteristic by cellular proliferation and disruption of arterial wall structure.
It’s may lead to dissection / aneurysm and tortuosity of vascular bed ( renal, cartoid, visceral, external iliac artery and coronary arteries).
It’s account 2 – 6.6% of kidney donor during evaluation.
It’s graded to ( I – IV ), according to severity; grade I mild/ grade IV severe.
This article shows no evidence of hypertension or proteinuria within 4 years of fallow up.
However after 15 years from fallow up there is no difference in change mortality regarding cardiovascular disease and hypertension.
This study recommended accept patients with FMD for donation and counselling regarding restrict fallow up.
Criteria of selected donor in this article is history included family history of hypertension and cardiovascular disease and diabetes and ESRD.
Cardiovascular disease means evidence of stroke and CCF and myocardial infraction.
The donor selected with no evidence of hypertension and diabetes and no proteinuria with eGFR >80 ml/min.
All donor do renal imagine (prior to 1999). was done by conventional angiography and CT angiography and MRA.
Note that fibromuscular dysplasia mainly unilateral and in right kidney more than left, it’s may be genetic in white female, so this females should excluded from donation.
Limitations of this study is small size group of FMD and short fallow up and no data regarding site of FMD.
W2: Level 3
Fibromuscular dysplasia (FMD) is a noninflammatory, nonatherosclerotic disorder that leads to arterial stenosis, occlusion, aneurysm, dissection, and arterial tortuosity. These findings have been observed in nearly every arterial bed
Patients with FMD have involvement of the renal arteries approximately 75 to 80 percent of the time and involvement of the extracranial cerebrovascular arteries (eg, carotid and vertebral arteries) approximately 75 percent of the time (UpToDate).
In the past, it was believed that FMD was a disease of young women. However, older individuals account for a large proportion of affected patients in several cohorts. As an example, in the United States FMD Registry, the mean age at diagnosis was 52 years, with a range of 5 to 97 years
The authors of this study have touched a very delicate issue. Shall we accept donors with FMD or no?
The Renal and Lung Living Donor Evaluation (RELIVE) study addressed long-term outcomes of 8922 kidney donors who donated between 1963 and 2007.
They compared the development of hypertension, cardiovascular disease (CVD), proteinuria and reduced estimated glomerular filtration rate (eGFR) in 113 kidney donors with FMD discovered during donor evaluation versus 452 propensity score matched donors without FMD.
Outcomes modeling with logistic and Cox regression analysis and Kaplan–Meier statistics were performed.
Donors with FMD were older (51 versus 39years), were more likely to be women (80% versus 56%) and had a higher systolic blood pressure at donation (124.7 versus 121.3 mmHg) (P < 0.05 for all).
After a mean 6 standard deviation follow-up of 15.5 6 8.9 years, a similar proportion of donors with and without FMD were alive, and developed hyper- tension (22.2% versus 19.8%), proteinuria (20.6% versus 13.7%) and CVD (13.3% versus 13.5%). No donor with FMD developed an eGFR <30 mL/min/1.73 m2 or end-stage kidney disease.
Kidney donors with FMD appear to do well, do not appear to incur increased risks of hypertension, proteinuria, CVD or reduced eGFR, and perhaps carefully selected.
In view of findings of current study candidates with FMD can safely donate as long as involvement of other vascular beds is ruled out.
It is a retrospective observational cohort study. Level 3
The article is based on the long-term outcomes of kidney donors with fibromuscular dysplasia (FMD). FMD is a pathology that is a non-atherosclerotic arterial disease with an unknown etiology. It is a disease that is found in about 2.0-6.6% of kidney donors during the investigation or study for possible kidney donors. The study was conducted by RELIVE with a population of 8922 kidney donors from a period of 1963-2007. The donors were followed up who had CVD, BP and proteinuria, and GFR.
During the investigation, it was found that 80% of females had FMD and were older donors. There was significantly elevated BP and decreased GFR in donors than in non-FMD donors. There was a right kidney donation with FMD. It was noted that CVD, DM, low GFR, and the level of proteinuria were the likely contributing cause of death in the two groups studied. As it related to having proteinuria it was found more frequently in the FMD donors than the non-FMD donors. The FMD never had a decrease of GFR in a severe manner and neither has ESRD.
The study was the largest group of FMD ever studied and with the longest follow-up. However, there were some limitations such as there no clear understanding as to the extent of the FMD and the number of vessels affected. There was no data to compare the outcome when relate to the recipients.
So one can conclude that donors with FMD can donate safely since their long-term outcomes are similar to other donors. After a long period of follow-up, FMD donors had similar proteinuria and BP when compared with non-FMD donors.
The level of evidence in this study was level 3
1-Summary of this article
Introduction
FMD is anon atherosclerotic arterial disease of unclear cause ,FMD is encounted in 2% -6% of kidney donors during evaluation of renal vasculature .
The goal of this analysis was to ascertain cardiovascular outcome since FMD is not confined to renal arteries and can lead to acute myocardial infraction and peripheral arterial disease
Method
The RELIVE study rolled 8922 live kidney donors from 1963 to 2007 donors with FMD are 113,family history of HTN ,DM ,kidney disease ,stroke or heart disease in donor first degree was recorded.
Result
113 donor with FMD ,in the propensity score matched comparison the two groups were highly comparable except for a higher like hood of family history of HTNA undergoing open nephrectomy .
CVS incidence ,myocardial infraction ,stroke ,transit ischemic attack, heart failure and need for coronary revascularization were similar between donors with and without FMD.
Discussion
FMD donors at time of kidney donation were not more likely to develop HTN or ad verse CVS or renal consequences.
Donors with FMD were less likely to have the left kidney removed, as right renal artery is more commonly involved with FMD than the left .
Inconclusion ,that some kidney donor with FMD can safely donated as their long -term incidence of mortality ,CVD and HTN and reduced eGFR is similar to the rest of the donor population
Recommendation regarding assessment of vascular bed in donors with FMD.
FMD should be seen at least annually for early HTN detection and sign of kidney function decline.
2- level3 retrospective study
This is a retrospective observational cohort study with three US centers collecting data between 1963 and 2007 (Level of Evidence 2b). The objective is to evaluate the evolution of kidney donors with fibromuscular dysplasia, a non-arteriosclerotic arterial disease of unknown cause. There are questions about development of hypertension, cardiovascular disease, proteinuria, and eGFR reduction.
The study looked at 8922 and contacts between 2010-2012 and identified 113 patients with fibromuscular dysplasia. A 4:1 score matching was performed, separating the groups into 452 and 113 donors. The fibromuscular dysplasia group is more frequent in older, female, Caucasian donors with lower eGFR than the control group. Regarding the results, cardiovascular disease, hypertension, and ESKD do not show a statistically significant difference. They are more likely to develop proteinuria (20.6 x 13.7%).
This study is the largest series of patients with fibromuscular dysplasia and with a very extended follow-up, but there were no records of how extensive the dysplasia was (unilateral, bilateral, multifocal). There was also a lack of data on the surgical procedure performed on the recipient.
The study suggests that donor candidates with fibromuscular dysplasia should be screened annually for early detection of hypertension and signs of loss of kidney function.
Summary:
· Fibromuscular dysplasia (FMD) is systemic vascular disease (not related to atherosclerosis) that can be discovered during work up before organ donation in 0.2-6.6 % of potential living kidney donors. It is characterized by abnormal structure of arterial wall that can affect carotid, renal, coronary and iliac arteries so it is associated with ischemic stroke, hypertension, myocardial infarction and peripheral arterial disease respectively.
· The current observational cohort aimed to compare donors with FMD and those without it, as regard eGFR, hypertension, proteinuria and cardiovascular outcomes as no current guidelines or recommendations in this aspect.
· FMD donors were older age and more commonly females. However, comparable outcomes were found when compared to none FMD donors after a mean of 15 years duration of follow up.
· So, the current study can provide recommendation for accepting some donors with FMD (after exclusion of other vascular site affection and with strict adherence to follow up yearly thereafter for development of hypertension or decline in GFR after donation) in order to expand the donor pool to solve the problem of living organ shortage.
· Exclusion of those who have iliac arteries affection, or having severe disease or bilateral renal artery affection.
· The renal arteries were the most common site of affection (75% of FMD cases), unilateral affection is more common than bilateral, and the right renal artery tended to be more affected than the left one.
· There are many limitations: no available data regarding
o The transplant centers” policy of dealing with FMD donors.
o The long -term outcomes of the recipients of the grafts from FMD donors.
o Pattern of FMD whether focal or multifocal, mild or severe affection.
Level of evidence: retrospective cohort (level III)
1. Please summarize this article in your own words
Background:
Fibromuscular dysplasia is a non-atherosclerotic arterial disease of unclear cause
Is manifested by dissection, aneurysm and tortuosity of many vascular beds such as the
renal, carotid, visceral, external iliac arteries and even the coronary arteries.
No recommendations regarding the use of kidneys from donors with FMD and there is a
paucity of data on the outcomes of these donors.
Methods.
The Renal and Lung Living Donor Evaluation (RELIVE) study addressed long-term
outcomes of 8922 kidney donors who donated between 1963 and 2007.
Outcome:
The development of hypertension, cardiovascular disease (CVD), proteinuria and
reduced estimated glomerular filtration rate in 113 kidney donors with FMD discovered
during donor evaluation versus 452 propensity score matched donors without FMD.
Results:
Donors with FMD were older, were more likely to be women and had a higher systolic
blood pressure at donation.
After a mean and standard deviation follow-up of 15.5 6 8.9 years, a similar proportion of
donors with and without FMD were alive, and developed hypertension (22.2% versus
19.8%), proteinuria (20.6% versus 13.7%) and CVD (13.3% versus 13.5%).
No donor with FMD developed an eGFR less than 30 or ESRD.
Discussion:
Donors with FMD IS more likely to develop hypertension or adverse cardiovascular or
renal consequences.
Conclusions:
Kidney donors with FMD appear to do well, do not appear to incur increased risks of
hypertension, proteinuria, CVD or reduced eGFR; candidates with FMD can safely
donate as long as involvement of other vascular beds is ruled out.
Limitation:
The extent of FMD (unilateral versus bilateral, univocal versus multifocal) is not captured
in the dataset. In addition, there is no information about the three participating centers’
approach to donors with FMD.
It is also not clear whether reconstruction of the FMD vessel was performed in the
recipient.
Lastly, we do not have data on the outcomes of the recipients of the donated kidney.
2. What is the level of evidence provided by this article?
Level of evidence 111
As a retrospective lecture (case-control), it has Level II of evidence. 113 cases of FMD were compared in 1:4 ratio matching. The lowest recorded 3 reading were considered for considering HT (to minimize the white coat effect). source of information is mostly previous records, with a small number of information taken from recipients of those donors. 3 centres participated with information from a total of 8922; 113 of them had FMD. Most participants were white (84.8% non -FMD / 90.3% with FMD).Donors with FMD were older (51 vs 39). and had lower basal eGFR (79 vs 88 ml/min/1.73m2). although the cause of death was ascertainable in 50% of donors, no difference was noted. Coronary artery revascularization also was nearly similar. as we can see in figure 2 (kaplan-Meier), HT was similar /parallel till the 15 years of follow-up but became prominent (higher number) before 20 years. the cardiovascular events were similar, and eGFR was similar on follow-up. As a result, we can conclude that donors with FMD can be acceptable donors in terms of extended pool donation if they are the option available after evaluation.
the conclusion of this study is showing that we can accept patient with FMD as a kidney donor as the study showed that After a mean 6 standard deviation follow-up of 15.56 8.9 years, a similar proportion of donors with and without FMD were alive, and developed hypertension (22.2% versus 19.8%), proteinuria (20.6% versus 13.7%) and CVD (13.3% versus 13.5%). No donor with FMD developed an eGFR <30 mL/min/1.73 m 2 or end-stage kidney disease. The multivariable risk of mortality, CVD and renal outcomes in donors with FMD was not elevated.
Fibromuscular dysplasia (FMD) is a non-atherosclerotic arterial disease of unclear cause [1]. It is characterized by abnormal cellular proliferation and disruption of the arterial wall structure, and is manifested by dissection, aneurysm and tortuosity of many vascular beds such as the renal, carotid, visceral, external iliac arteries and even the coronary arteries [2]. The growing awareness and importance of FMD is evidenced by the recent publication of the First International Consensus on the diagnosis and management of FMD [1]. FMD is encountered in 2.0–6.6% of kidney donors during evaluation of renal vasculature [3–6]. There are limited data on how transplant centers approach donor candidates with FMD, and published transplant societies guidelines do not address this issue. Moreover, there are only a few case series that have addressed outcomes of donors with FMD.
They compared the outcomes of kidney donors with FMD to those without; after 15.5 6 8.9years of follow-up, there were no differences in mortality, cardiovascular disease, hypertension development, proteinuria or reduced kidney function between donors with and without FMD.
Donors with FMD were older (51 versus 39 years), were more likely to be women (80% versus 56%) and had a higher systolic blood pressure at donation (124.7 versus 121.3 mmHg) (P< 0.05 for all). After a mean 6 standard deviation follow-up of 15.56 8.9 years, a similar proportion of donors with and without FMD were alive, and developed hypertension (22.2% versus 19.8%), proteinuria (20.6% versus 13.7%) and CVD (13.3% versus 13.5%). No donor with FMD developed an eGFR <30 mL/min/1.73 m 2 or end-stage kidney disease. The multivariable risk of mortality, CVD and renal outcomes in donors with FMD was not elevated.
Conclusions. Kidney donors with FMD appear to do well, do not appear to incur increased risks of hypertension, proteinuria, CVD or reduced eGFR, and perhaps carefully selected candidates with FMD can safely donate as long as involvement of other vascular beds is ruled out.
the favorable observed long-term outcomes in kidney donors with FMD provide justification for accepting some donor candidates with FMD; and
it may also provide transplant centers with information that can be used for informed consent in accepting donor candidates with FMD provided involvement of other vascular beds is excluded and the recommended follow-up guidelines for those with FMD advocated for by FMD Registries are adhered to.
level 3
Fibromuscular dysplasia (FMD) can be incidentally detected (2-6.6%) in prospective donors. FMD is associated with hypertension and may cause stroke, myocardial infarction or peripheral vascular disease. There is no data/ guidelines available regarding kidney donation by FMD patients.
The study involved comparing outcomes of donors (from 1963-2007) with FMD (113 in number) with matched donors without FMD (452 in number) with respect to development of hypertension, cardiovascular disease, proteinuria and fall in GFR for a mean follow-up of 15.5±8.9 years. It was done from the dataset of RELIVE study involving 3 transplant centres in USA.
Donors with FMD were older, more women, more whites, more likely to be unrelated to their recipients, having higher systolic blood pressure and had reduced baseline eGFR.
Donors with FMD, when compared to the whole donor cohort, had increased history of first degree relative with hypertension or heart disease, increased dyslipidemia, single renal artery in non-donated kidney, less likely that left kidney was removed and laparoscopic nephrectomy was done. When compared to the matched donors without FMD, Donors with FMD had significant difference with respect to history of first degree relative with hypertension, single renal artery in non-donated kidney and less chances of removal of left kidney.
There was no difference between the 2 groups with respect to hypertension, cardiovascular disease (MI, TIA, stroke, heart failure and revascularization), ESRD development or death. Donors with FMD were more likely to develop proteinuria than the total cohort of donors (20.6% versus 13.7%), although it was similar to the matched group of donors.
The strengths of the study included being largest study with longest follow-up among donors with FMD and the outcomes were ascertainable.
The limitations of the study include lack of details regarding the extent of FMD, no details available regarding approach towards donors with FMD in the transplant programs (with chances of exclusion of donors with severe FMD), lack of data regarding focal/ multi-focal FMD, lack details regarding reconstruction of FMD vessels and lack of data regarding recipient outcomes receiving kidneys from such donors.
The study demonstrates that donors with FMD can safely donate kidneys with long-term outcomes similar to donors without FMD. Such donors should be followed-up annually for detection of hypertension and renal dysfunction.
2. What is the level of evidence provided by this article?
Level of evidence is level 3: Retrospective cohort study
Fibromuscular dysplasia (FMD) is a non-atherosclerotic arterial disease of unclear cause
It is characterized by abnormal cellular proliferation and disruption of the arterial wall structure, and is manifested by dissection, aneurysm and tortuosity of many vascular beds such as the renal, carotid, visceral, external iliac arteries and even the coronary arteries
After a follow-up of 4 years, none of 19 donors with grade I
(mild) or grade IV (severe) FMD lesions reported by Indudhara et al. developed hypertension or reduced glomerular filtration rate (GFR). In contrast, 26.3% ofdonors reported by Cragg et al. developed hypertension in 4.4 years.
MATERIALS AND METHODS
8922 live kidney donations at the study sites from 1963 to 2007. Family history ofhypertension, diabetes mellitus (DM), kidney disease, stroke or heart disease in donors’ first-degree relatives was recorded. Blood pressure readings were collected on multiple occasions during the donor evaluation and the average of the three lowest blood pressure measurements was used as a baseline blood pressure value. The choice of the lowest recorded readings was an attempt to avoid misclassification of donors with white coat hypertension as truly hypertensive. Hypertension at baseline and at follow-up was defined as use ofantihypertensive medications, a systolic blood pressure (SBP) >140mmHg or a diastolic blood pressure >90mmHg. The participating study sites contacted donors between 2010 and 2012 for follow-up and outcomes.
RESULTS and DISCUSSION
These results demonstrate that kidney donors who had FMD in the donated kidney at the time of kidney donation were not more likely to develop hypertension or adverse cardiovascular or renal consequences
FMD affects the renal arteries in 75% ofthe cases, 74% of the carotid arteries and 33% of the vertebral arteries
Clinically, patients with FMD present with hypertension and 35% may present with stroke or transient ischemic attack secondary to carotid and vertebral artery dissection.
Studies that have addressed outcomes of kidney donors with FMD have been small in size and had a very short follow-up
long-term recipient outcomes from FMD donors did not differ from recipients of non-FMD kidneys [8]. Two other series have shown similar results. On the other hand, there have been sporadic cases of hypertension development and renal dysfunction in some donors with FMD
Donors with FMD were less likely to have the left kidney removed. This raises three possibilities. First, FMD was present in the right kidney only and the choice was made to leave the donor with the disease-free kidney.
This is very plausible as the right renal artery is more commonly involved with FMD than the left: 33.8% versus 11.6% of unilateral FMD cases .Second, FMD was bilateral, as seen in 32–40% of FMD cases published in the literature but the left kidney was less affected
Donors with FMD were an average 12 years older than those without FMD, which is the typical profile of those with FMD, who tend to be middle-aged female, White with a family history of hypertension. Donors with FMD were more likely to be unrelated to their recipient and were more likely to be White. It is possible, therefore, that these donors were less likely to donate to recipients with a strong component ofgenetic kidney diseases, which typically present earlier in life.
strengths.
this is the largest
series of kidney donors with FMD that has been studied and with the longest follow-up. The outcomes of interest were ascertainable in the majority of donors. Nevertheless, there are limitations. The extent of FMD (unilateral versus bilateral, unifocal versus multifocal) is not captured in the dataset. In addition, there is no information about the three participating centers’ approach to donors with FMD.
Conclusion
some kidney donors with
FMD can safely donate as their long-term incidence ofmortality, CVD and hypertension, and reduced eGFR is similar to the rest of the donor population. Newly introduced recommendations regarding assessment of all vascular beds for the presence ofFMD should be strongly considered when donors with FMD are considered for kidney donation. Obviously, in recipients with multiple potential donors, the ones with FMD can perhaps be considered last. Importantly, if donor candidates with FMD are to be accepted they should be seen at least annually for early hypertension detection and signs ofkidney function decline.
level II
FMD is a non-atherosclerotic systemic arterial disease of unclear etiology, detected in 2-6.6% of kidney donors during evaluation of renal vessels.
No available recommendations regarding accepting potential donors with FMD and available data on the outcome of those donors is scarce.
Studies about donors with FMD had several limitations as inclusion f small number of donors with FMD, short term follow up and absence of data about CVD post donation.
This study aimed to determine the risk of developing HTN, CVD, proteinuria and decreased eGFR in donors with FMD.
CVD is a concern in those donors as it may lead to other arterial consequences as stroke, acute MI and PAD.
The study used de-identified donor information publicly available from the RELIVE study, 113 donors with FMD discovered during donor evaluation were compared to 452 propensity score matched without FMD.
The study showed that kidney donors who had FMD in donated kidney were not at increased risk of HTN, cardiovascular or renal complications.
Donors with FMD were less likely to have left kidney removed, may be due to affection of right kidney only and leaving the donor with the disease-free kidney as FMD more commonly affect right renal artery, FMD was bilateral but the left kidney was less affected or fewer nephrectomies performed on the left due to presence of multiple arteries on the left side.
Donors with and without FMD had similar prevalence of kidney cysts and stones in the donated and non-donated kidneys.
Donors with FMD tend to be middle aged females, white with a family history of HTN and were more likely to be unrelated.
The study suggested that kidney donors with FMD can be safely accepted for donation with considering the assessment of all vascular beds for presence of FMD during the evaluation with annual follow up after donation for early detection of HTN and any decline in kidney function.
Strengths:
Among available studies, this study included the largest series of donors with FMD with the longest follow up
Outcomes of interest were ascertainable in most donors.
Limitations:
Data about extent of FMD was not available.
No information about approach to donors with FMD in the 3 centers participating in the RELIVE study
Also, whether reconstruction of FMD vessel was performed in recipient is unclear
No data about the outcome of recipients
Level 3 (Retrospective study)
Please summarise this article in your own words
-Fibromuscular dysplasia (FMD) is a non-atherosclerotic arterial disease of unclear cause . FMD is encountered in 2.0–6.6% of kidney donors during evaluation of renal vasculature .
-The Renal and Lung Living Donor Evaluation (RELIVE) study addressed long-term outcomes of 8922 kidney donors who donated between 1963 and 2007.
-The results demonstrate that kidney donors who had FMD in the donated kidney at the time of kidney donation were not more likely to develop hypertension or adverse cardiovascular or renal consequences.
-FMD affects the renal arteries in 75% of the cases, 74% of the carotid arteries and 33% of the vertebral arteries .
-Once a FMD diagnosis is made, patients should have onetime head-to-pelvic cross-sectional vascular imaging with CT angiography. These recommendations came into existence after 2012 .
-Donors with FMD were less likely to have the left kidney removed. This raises three possibilities. First, FMD was present in the right kidney only and the choice was made to leave the donor with the disease-free kidney.
-Second, FMD was bilateral, but the left kidney was less affected. This is also plausible as even when FMD is bilateral the right kidney appears to have more significant disease . Third, it is possible that fewer left nephrectomies were performed due to the presence of multiple arteries on the left.
– Donors with FMD were an average 12 years older than those without FMD, which is the typical profile of those with FMD, who tend to be middle-aged female, White with a family history of hypertension.
-The study has strengths: it is the largest series of kidney donors with FMD that has been studied and with the longest follow-up. The outcomes of interest were ascertainable in the majority of donors.
– The limitations : The extent of FMD (unilateral versus bilateral, unifocal versus multifocal) is not captured in the dataset. In addition, there is no information about the three participating centers’ approach to donors with FMD. It is possible that the donors with FMD who were included in the analysis had mild disease, since perhaps individuals with severe disease were not allowed to donate.
Lastly, they do not have data on the outcomes of the recipients of the donated kidney.
-In all, these data demonstrate that some kidney donors with FMD can safely donate as their long-term incidence of mortality, CVD and hypertension, and reduced eGFR is similar to the rest of the donor population. Newly introduced recommendations regarding assessment of all vascular beds for the presence
of FMD should be strongly considered when donors with FMD are considered for kidney donation. Obviously, in recipients with multiple potential donors, the ones with FMD can perhaps be considered last. Importantly, if donor candidates with FMD are to be accepted they should be seen at least annually for early hypertension detection and signs of kidney function decline.
What is the level of evidence provided by this article?
Level 2
Methods
8922 donors from 1962 to 2007
Follow up each of CVD- BP- proteinuria- eGFR
113 donors with FMD discovered during evaluation
452 propensity score matched donors without FMD
Kaplan’s statistics
Results
Donors with FMD was older – 80% women-
SBP was higher and eGFR was lower at donation than non FMD donor
Open nephrectomy, right kidney donation were significantly higher in donors with FMD
After a mean follow-up of 15.568.9 years
There were no differences in the distribution of cause of death between the two groups.
Regarding CVD incidence were similar between donors with and without FMD.
developed hypertension (22.2% versus 19.8%)
Donors with FMD were more likely to develop proteinuria(20.6versus13.7%)(P¼0.04) ;however, there were no differences in outcomes
study has strengths
this is the largest series of kidney donors with FMD with the longest follow-up.
limitations.
Leve III
Please summarise this article in your own words
Fibromascular dysplasia is non atherosclerotic arterial disease due to abnormal endothilial cell proliferation disease causing arterial wall aneurysms and disruption manifested by dissection tortuosity of vascular beds, it affects the renal arteries in 75% of the cases, 74% of the carotid arteries and 33% of the vertebral arteries.
2-6.6% of kideny donors found to have fibromascular dysplasia.
Study design:
8922 kidney donors from 1963-2007, were collected from RELIVE study, in three centers, 113 donors with FMD, compared with 452 with no fibromuscular dysplasia, were enrolled 1:4 ratio, with a mean follow up of 15.5+/-8.9 years.
The family history for HTN, DM, kidney disease, stroke, or heart disease in all donors was reported.
B/P >140/90 mmHg considered as hypertension
ESKD was defined by need for dialysis, or receiving or being listed for a kidney transplant.
CVD defined defined by any myocardial infarction, congestive heart failure, transient ischemic attack, stroke, or need for coronary or peripheral arterial intervention.
Proteinuria defined as one or more of the following: urine protein by dipstick >+2, urine protein/osmolality >0.42 ratio, urine random protein >15 mg/dL or 24-h protein >300 mg/day.
Results:
= Donors with FMD were older (51 versus 39 years), and were more likely to be women (80% versus 56%) and White (90.3% versus 84.7%) (P< 0.05).
= Baseline eGFR was also lower in donors with FMD (79 versus 88 mL/ min/1.73 m2),
(P < 0.001).
= Right kidney donation were significantly higher in donors with FMD,having one artery
= CVD, diabetes development, proteinuria status, and eGFR, Cause of death were comparable in both study group.
= Donors with FMD, compared to donors without FMD, were more likely to develop proteinuria (P= 0.04).
= Non of those with FMD experienced decrease eGFR<30ml/min/1.73m2, or ESKD.
= Donors with FMD had a single renal artery in the non-donated kidney in 78.8% of cases compared with 61.6% of donors without FMD(P = 0.01).
Strength of the study:
Largest series of kidney donors with FMD that has been
studied and with the longest follow-up.
The outcomes of interest were collected in all donors.
Limitations of the study:
The extent of FMD (unilateral/ bilateral, unifocal/ multifocal) is not captured in the dataset.
No information about the three participating centers’approach to donors with FMD.
No data on the outcomes of the recipients of the donated kidney.
Conclusion:
Kidney donors with FMD can safely donate as their long-term incidence of mortality, CVD and hypertension, and reduced eGFR is similar to the rest of the donor population.
Patients with diagnosis of FMD should have onetime head-to-pelvic cross-sectional vascular imaging with CT angiography, when considered as donors, and should be followed annually for early detection of hypertension, and sign of kidney function decline.
What is the level of evidence provided by this article?
Level of evidence III – retrospective cohort
SUMMARY
Introduction
Fibromuscular dysplasia (FMD) is non atherosclerotic vascular disease commoner among women and characterized with excessive growth and proliferation of arteria wall anatomy. It can affect the vessels of the kidney, brain, heart, GIT and carotid vessels. Many of the available guidelines do not provide enough evidence on the use of the kidney from individuals with FMD despite the incidence of 2.0% – 6.6 % among potential donors during work up
Aim/goal
Materials and methods
Result
Conclusion
This study has shown that donors with FMD were not at a higher risk for CVD event, hypertension or any renal abnormality outcome compared to those with FMD. Similarly, following 16 years of follow up, it was found that donors with FMD had similar blood pressure and protein excretion as those donors without FMD.
Level of evidence is 3, retrospective observational
# Please summarise this article in your own words
# The objective:
To study the development of HTN, CVD, proteinuria and reduced e-GFR in a large cohort of kidney donors with FMD.
# Introduction:
*Fibromuscular dysplasia (FMD) is a non-atherosclerotic arterial disease of unknown etiology, in which there is abnormal cellular proliferation and disruption of the arterial wall structure presented by dissection, aneurysm and tortuosity of many vascular beds such as the renal, carotid, visceral, external iliac arteries and even the coronary arteries
*FMD is encountered in 2.0–6.6% of kidney donors during evaluation of renal vasculature.
*There are limited data on how transplant centers approach donor with FMD and only few case that showed the outcomes, in addition to that, the published transplant society’s guidelines do not conducted recommendation.
# Material and methods:
The (RELIVE) study was a National Institutes of Health-sponsored effort that studied donor outcomes from the University of Minnesota, Mayo Clinic–Rochester and the University of Alabama–Birmingham.
*There were 8922 live kidney donations at the study sites from 1963 to 2007.
* Family history of HTN, DM, kidney disease, stroke or heart disease in donors’ first-degree relatives was recorded.
*BP readings were collected on multiple occasions during the donor evaluation with using the average.
*Donors filled out quality of life surveys, health questionnaires regarding the development of CVD. HTN, hypertension,DM, RFT and other conditions.
*Laboratory data and records from their private physicians.
# Results:
* Donors with FMD were older and were more likely to be women and White.
* Baseline eGFR was also lower in donors with FMD.
*Open nephrectomy, right kidney donation and likelihood of the remaining kidney having just one artery were significantly higher in donors with FMD.
*The two groups were highly comparable except for a having family history of HTN, undergoing open nephrectomy, right kidney removal and having a singular artery in the non donated kidneys in donors with FMD.
*Vital status was ascertainable in 99.8% of donors, CVD (90.2%), proteinuria (89.9%), and e GFR ( 97.1%.).
*Cause of death was available for roughly 50% of all donors, and there were no differences in the distribution of cause of death between the two groups.
*MI, stroke, TIAs, HF and need for coronary revascularization were similar between donors with and without FMD.
*After a mean follow-up of 15.568.9 years, 13.5% of donors without FMD developed CVD, 19.8% developed hypertension, 13.7% developed proteinuria and 0.6% developed ESKD. *The corresponding proportions in donors with FMD were 13.3, 22.2 and 20.6%, and none developed Egfr <30mL/min/1.73m2 or ESKD.
* Donors with FMD, compared with the entire donor cohort without FMD, were more likely to develop proteinuria.
*The strengths of the study are that, largest series of kidney donors with FMD that has been studied and with the longest follow-up and the outcomes of interest were ascertainable in the majority of donors.
*The limitations of the study are that, the extent of FMD is not captured in the dataset.
No information about the three participating centers’ approach to donors with FMD.
It is also not clear whether reconstruction of the FMD vessel was performed in the
recipient.
No data on the outcomes of the recipients of the donated kidney.
*Newly introduced recommendations regarding assessment of all vascular beds for the presence of FMD should be strongly considered when donors with FMD are considered for kidney donation.
# Conclusion:
Kidney donors with FMD appear to do well and do not appear to incur increased risks of HTN, CVD or reduced eGFR.
Carefully selected candidates with FMD may be able to donate a kidney safely.
# What is the level of evidence provided by this article?
*It is retrospective cohort study level 3.
Thank you
Long-term outcomes of kidney donors with fibromuscular dysplasia
Summary
This is a retrospective study in the Renal and Lung Living Donor Evaluation (RELIVE) in USA, addressed long-term outcomes of 8922 kidney donors who donated between 1963 and 2007. The study compared the development of hypertension, cardiovascular disease (CVD), proteinuria and reduced estimated glomerular filtration rate (eGFR) in 113 kidney donors with FMD discovered during donor evaluation versus 452 propensity score matched donors without FMD
MATERIALS AND METHODS:
The study populations: participants kidney donors from RELIVE study from 3 US transplant centers, who donated between 1963 and 2007.
113 kidney donors with FMD compared with 452 propensity score matched donors without FMD, matching (4 controls : 1 case) for long the development of HTN, CVD, proteinuria and reduced eGFR rate
The participating study sites contacted donors between 2010and 2012 for follow-up and outcomes,which defined as:
CVD:any of the following: MI , CHF, TIA, stroke, or need for coronary or peripheral arterial intervention (angioplasty, stenting or bypass).
ESKD: need for dialysis, or receiving or being listed for a kidney transplant.
HTN: as use of antihypertensive medications, SBP>=140mmHg or a DBP>=90mmHg.
Proteinuria: as one or more of the following: urine protein by dipstick 2., urine protein/osmolality
>0.42 ratio, urine random protein >15mg/dL or 24-h protein >300mg/day.
Exclusion: any donors with proteinuria, measured GFR or creatinine clearance <80mL/min.
Result
-Were 8922 live kidney donations at the three centers between 1963 and 2007 .
Donors with FMD were older (51 versus 39 years).
Donor were more likely to be women (80% versus 56%). and White (90.3% versus 84.7%) .
Baseline eGFR was also lower in donors with FMD (79 versus 88 mL/min/1.73 m2
Open nephrectomy, right kidney donation and likelihood of the remaining kidney having just one artery were higher in donors with FMD.
The survival was similar in both FMD and non-FMD donors.
Hypertension was insignificantly higher in FMD donors than non-FMD donors ( 22.2 versus 19.8%)
Cardiovascular disease was almost equal in both groups of donors ( 13.3 versus 13.5 %)
Proteinuria was slightly higher in FMD donors than non-FMD donors ( 20.6 versus 13.7%)
None of FMD donors developed ESRD or GFR less than 30 ml/min.
Strengths of the study :
Large sample size
Limitations :
Extent of FMD not captured in the dataset – thus mild disease donors have been included while severe FMD candidates have not been allowed to donate, thus allowing opportunity for skewing of results.
Missing distinction between focal and multifocal FMD.
Conclusion:
Donor with FMD can be included in donation as there is no increase in the risk of proteinuria .hypertension ,cardiovascular disease and chronic kidney disease after donation if selected well.
Donors with FMD should have follow up of blood pressure and assessment of kidney functions at least once per years.
What is the level of evidence provided by this article
Level of evidence 3 ,retrospective Cohort study
Thank you, in addition, no date regarding the outcome in the recipients.
Introduction :
Fibromuscular dysplasia (FMD) is a non-atherosclerotic arterial disease, of no clear cause.
Charecteristic:
FMD is encountered in 2.0-6.6% of KD during evaluation of donor vasculature, but yet no published guidelines in dealing with FMD.
Material and methods:
Statistical Analysis:
Results:
Discussion:
Level of evidence ;
Observational cohort ((III))
Thank you
Long-term outcomes of kidney donors with fibromuscular dysplasia
Summary
This is a retrospective study in the Renal and Lung Living Donor Evaluation (RELIVE) in USA, addressed long-term outcomes of 8922 kidney donors who donated between 1963 and 2007. The study compared the development of hypertension, cardiovascular disease (CVD), proteinuria and reduced estimated glomerular filtration rate (eGFR) in 113 kidney donors with FMD discovered during donor evaluation versus 452 propensity score matched donors without FMD.
Study’s results and outcome
Kidney donors with FMD appear to do well, do not appear to incur increased risks of hypertension, proteinuria, CVD or reduced eGFR.
Limitations of the study
a) Small number of donors with FMD studied.
b) Short-term follow-up.
c) The extent of FMD (unilateral versus bilateral, unifocal versus multifocal) is not captured in the dataset.
d) There is no information about the three participating centers’ approach to donors with FMD.
e) It is not clear whether reconstruction of the FMD vessel was performed in the recipient.
f) No data on the outcomes of the recipients of the donated kidney.
g) The lack of outcomes data on major cardiovascular events after donation.
strengths of the study
a) It is the largest series of kidney donors with FMD that has been studied and with the longest follow-up.
b) The outcomes of interest were ascertainable in the majority of donors.
The level of evidence provided by this article:
This is a retrospective cohort study
Level of evidence grade 3.
Thank you
FMD is encountered in 2.0–6.6% of kidney donors during evaluation of renal vasculature. Current guidelines
do not provide recommendations regarding the use of kidneys from donors with FMD and there is a paucity of data on the outcomes of these donors.
MATERIALS AND METHODS:
The study populations: participants kidney donors from RELIVE study from 3 US transplant centers, who donated between 1963 and 2007.
113 kidney donors with FMD compared with 452 propensity score matched donors without FMD, matching (4 controls : 1 case) for long the development of HTN, CVD, proteinuria and reduced eGFR rate
The participating study sites contacted donors between 2010and 2012 for follow-up and outcomes,which defined as:
CVD:any of the following: MI , CHF, TIA, stroke, or need for coronary or peripheral arterial intervention (angioplasty, stenting or bypass).
ESKD: need for dialysis, or receiving or being listed for a kidney transplant.
HTN: as use of antihypertensive medications, SBP>=140mmHg or a DBP>=90mmHg.
Proteinuria: as one or more of the following: urine protein by dipstick 2., urine protein/osmolality
>0.42 ratio, urine random protein >15mg/dL or 24-h protein >300mg/day.
Exclusion: any donors with proteinuria, measured GFR or creatinine clearance <80mL/min.
Results:
Donors with FMD were older, were more likely to be women and had a higher systolic blood pressure at donation (124.7 versus 121.3mmHg) (P<0.05 for all).
Higher likelihood of having family history of hypertension, undergoing open nephrectomy, right kidney removal and having a singular artery in the nondonated kidneys in donors with FMD.
The mean follow-up of 15.5 years.
After follow-up similar proportion of donors with and without FMD were alive, and developed hypertension (22.2% versus 19.8%), proteinuria (20.6% versus 13.7%) and CVD (13.3% versus 13.5%).
No donor with FMD developed an eGFR <30mL/min/1.73 m2 or end-stage kidney disease.
The multivariable risk of mortality, CVD and renal outcomes in donors with FMD was not elevated.
Limitations:
– The extent of FMD (unilateral vs bilateral, unifocal vs multifocal) is not captured in the dataset
– Approach of the centers to donors with FMD was not mentioned, disease severity, other vessels involvement.
– It is also not clear whether reconstruction of the FMD vessel was performed in the recipient.
– The outcomes of the recipients was not available.
Conclusions. Kidney donors with FMD appear to do well, do not appear to incur increased risks of hypertension, proteinuria, CVD or reduced eGFR, and perhaps carefully selected candidates with FMD can safely donate as long as involvement of other vascular beds is ruled out.
Level of evidence:
Level 3, retrospective cohort study
Thank you
♧ Introduction:
▪︎ Fibromuscular dysplasia (FMD) is a non-atherosclerotic arterial disease of unclear cause. FMD is encountered in 2.0–6.6% of kidney donors during evaluation of renal vasculature.
▪︎There are limited data on how transplant centers approach donor candidates with FMD, and published transplant societies guidelines do not address this issue.
▪︎This analysis has studied the development of HTN, CVD, proteinuria and reduced eGFR in a large cohort of kidney donors with FMD.
▪︎The goal of this analysis was to ascertain CVD outcomes since FMD is not an abnormality that is confined to the renal arteries in the majority of cases, and can lead to serious arterial consequences such as stroke, acute MI and PAD.
♧Methods:
▪︎The RELIVE study addressed long-term outcomes of 8922 kidney donors who donated between 1963 and 2007.
▪︎This study compared the development of HTN, CVD, proteinuria and reduced eGFR in 113 kidney donors with FMD discovered during donor evaluation vs 452 propensity score matched donors without FMD.
▪︎Outcomes modeling with logistic and Cox regression analysis and Kaplan–Meier statistics were performed.
♧ Results:
▪︎Donors with FMD were older (51 vs 39yrs), were more likely to be women (80% vs 56%) and had a higher systolic blood pressure at donation (124.7 vs 121.3 mmHg) (P< 0.05 for all).
▪︎After a mean 6 standard deviation follow-up of 15.5 6 8.9 years, a similar proportion of donors with and without FMD were alive, and developed HTN (22.2% vs 19.8%), proteinuria (20.6% vs 13.7%) and CVD (13.3% vs 13.5%). No donor with FMD developed an eGFR <30 mL/min/1.73 m2 or ESRD.
▪︎The multivariable risk of mortality, CVD and renal outcomes in donors with FMD was not elevated.
♧Strengths of the study:
1. Largest series of kidney donors with FMD that has been studied and with the longest follow-up.
2. The outcomes of interest were ascertainable in the majority of donors.
♧Limitations:
1. The extent of FMD (unilateral versus bilateral, unifocal versus multifocal) is not captured in the dataset.
2. There is no information about the three participating centers’ approach to donors with FMD.
3. Perhaps individuals with severe disease were not allowed to donate so they are not included in this study.
4. The distinction between focal and multifocal FMD, while missing from the dataset, is perhaps not highly relevant.
5. It is also not clear whether reconstruction of the FMD vessel was performed in the recipient.
6. There is no data on the outcomes of the recipients of the donated kidney.
♧Conclusions:
▪︎The result of this study data demonstrated that some kidney donors with FMD can safely donate as their long-term incidence of mortality, CVD, HTN, and reduced eGFR is similar to the rest of the donor population. ▪︎Newly introduced recommendations regarding assessment of all vascular beds for the presence of FMD should be strongly considered when donors with FMD are considered for kidney donation.
▪︎In recipients with multiple potential donors, the ones with FMD can perhaps be considered last.
▪︎If donor candidates with FMD are to be accepted they should be seen at least annually for early HTN detection and signs of kidney function decline.
☆Level of evidence: III
Thank you
Thank you
Summary:
Aim of the study:
to ascertain cardiovascular outcomes in donors with FMD.
Methods:
data from RELIVE study ( 113 kidney donors with FMD discovered during donor evaluation versus 452 propensity score matched donors without FMD).
To compare the development of hypertension, cardiovascular disease, proteinuria and reduced estimated glomerular filtration rate in kidney donors with FMD to donors without FMD.
Results.
Donors with FMD were older, more likely to be women and had higher systolic blood pressure at donation.
After a mean +- standard deviation follow-up of 15.5 +- 8.9 years, a similar proportion of donors with and without FMD were alive and developed hypertension (22.2% versus 19.8%), proteinuria (20.6% versus 13.7%) and CVD (13.3% versus 13.5%).
No donor with FMD developed an eGFR <30 mL/min/1.73 m2 or end-stage kidney disease.
The multivariable risk of mortality, CVD and renal outcomes in donors with FMD was not elevated.
Conclusion:
Kidney donors with FMD appear to do well, do not appear to incur increased risks of hypertension, proteinuria, CVD or reduced eGFR, and perhaps carefully selected candidates with FMD can safely donate as long as the involvement of other vascular beds is ruled out.
Strength:
Limitations:
Level 3 (retrospective cohort study).
Thank you
● FMD is encountered in 2.0–6.6% of kidney donors during evaluation of renal vasculature
● fibromuscular dysplasia (FMD) of the renal artery is associated with hypertension and involves many vascular beds resulting in stroke, myocardial infarction and peripheral arterial disease
● Study includes 3 centers in USA
● Renal and Lung Living Donor Evaluation (RELIVE) study addressed long-term outcomes of 8922 kidney donors who donated between 1963 and 2007
● Donors with FMD compared to donors without FMD
● Outcomes : hypertension, (CVD), proteinuria and reduced eGFR
● Follow up 15.5 6 8.9 years
● Result : there were no differences in mortality, cardiovascular disease, hypertension development, proteinuria or reduced kidney function between donors with and without FMD.
● Conclusion : Kidney donors with FMD appear to do well, do not appear to incur increased risks of hypertension, proteinuria, CVD or reduced eGFR, and perhaps carefully selected candidates with FMD can safely donate as long as involvement of other vascular beds is ruled out.
● The strength of study :
** It is the largest series of kidney donors with FMD that has been studied and with the longest follow-up.
** The outcomes of interest were ascertainable in the majority of donors.
● Limitations :
** The extent of FMD (unilateral versus bilateral, unifocal versus multifocal) is not captured in the dataset.
** There is no information about the three participating centers’ approach to donors with FMD
** The distinction between focal and multifocal FMD, while missing from the dataset, is perhaps not highly relevant as collectively the available evidence suggests that these are two distinct entities rather than multifocal FMD being a result of progressive focal FMD
** It is not clear whether reconstruction of the FMD vessel was performed in the recipient.
** There is no data on the outcomes of the
recipients of the donated kidney.
● The impact this study on practice
◇ the favorable observed long-term outcomes in kidney donors with FMD provide justification for accepting some donor candidates with FMD
◇ it provide transplant centers with information that can be used for informed consent in accepting donor candidates with FMD provided involvement of other vascular beds is excluded and the recommended follow-up guidelines for those with FMD advocated for by FMD Registries are adhered to.
● Level evidence : III
Thank you
IV. Long-term outcomes of kidney donors with fibromuscular dysplasia (FMD)
Please summarise this article in your own words
Introduction
FMD of the renal artery is associated with HTN & involves many vascular beds (carotid, visceral, external iliac arteries & coronary arteries).
It is a non-atherosclerotic arterial disease of unclear cause.
FMD can result in stroke, MI & PAD.
FMD is seen in 2.0–6.6% of kidney donors.
Data on how transplant centers deal with potential donors with FMD are sparse, & only a few case series have addressed outcomes of donors with FMD.
Indudhara et al (19 donors with FMD, followed for 4 years): none developed HTN or reduced GFR.
Cragg et al: 26.3% of donors developed HTN in 4.4 years.
A recent study of 38 donors with FMD reported similar BP & UACR compared to those with no FMD over >10 years of follow -up.
The study
Aim
To study the development of HTN, CVD, proteinuria & reduced eGFR in a large cohort of kidney donors with FMD.
Methods
RELIVE study: a National Institutes of Health -sponsored effort that studied donor outcomes from the U of M, Mayo Clinic–Rochester & U of Alabama–Birmingham. Population: 8922 LKDs from 1963 to 2007. FH of HTN, DM, kidney disease, stroke or heart disease in donors’ 1st-degree relatives was recorded.
BP readings on multiple occasions & the average of the 3 lowest BP readings were used as a baseline BP value; the lowest readings use was to avoid misclassification of donors with white coat HTN as truly hypertensive.
HTN was defined as use of medications, a SBP =/>140mmHg or a DBP =/> 90mmHg.
Donors filled out QOL surveys, health
questionnaires regarding the development of heart disease, HTN, DM, kidney function & other conditions.
Laboratory data & records from their private physicians were provided.
CVD defined by any of the following:
MI
CHF
TIA
Stroke
Need for arterial intervention (angioplasty,
stenting or bypass).
ESKD defined by need for dialysis, or receiving or being listed for a kidney TX. Proteinuria defined as 1 or more of the following:
Urine protein by dipstick =/>2
Urine protein/osmolality >0.42 ratio
Urine random protein >15mg/Dl
24-h protein >300mg/day.
How FMD was defined & how the candidacy of donors with FMD defined are not specified in the RELIVE dataset.
Statistics
Frequencies & proportions used for categorical variables & median & IQR for continuous variables.
Chi-square or Fisher’s exact tests for categorical variables.
Kruskal–Wallis test for continuous variables. HTN, proteinuria, eGFR <60mL/min, <45mL/ min & <30mL/min, & CVD development were compared in donors with FMD (case)
vs those without FMD (control).
Propensity score matching: ratio of 1:4(1 case per 4 controls).
Kaplan–Meier method used to estimate cumulative incidence for outcomes.
Logistic regression and
Adjusted risks for the outcomes of interest estimated by Cox proportional-hazards modeling.
All the analyses were performed on Stata version 16.1.
P-value of <0.05 considered significant.
Results
Donors with FMD were older (51 vs 39), & more likely to be women (80% vs 56%) & White (90.3% vs 84.7%) (P<0.05 for all). Baseline eGFR was also lower in donors with FMD (79 vs 88mL/min, P<0.001).
Open nephrectomy, RK right donation & likelihood of the remaining kidney having just one artery were higher in donors with FMD.
The 2 groups were highly comparable except for a higher likelihood of having FH of HTN, open nephrectomy, RK removal & having a singular artery in the non-donated kidneys in donors with FMD.
Vital status ascertainable in 99.8% of donors, CVD development in 98%, DM in 90.2%, urinary protein assessment & proteinuria status in 89.9%, & eGFR values in 97.1% of donors.
Cause of death available for 50% of donors. No differences in distribution of cause of death between the 2 groups.
CVD incidence: MI, stroke, TIAs, HF & need for coronary revascularization were similar between donors with & without FMD.
After a mean follow-up of 15.5+/-8.9 years: 13.5% of donors without FMD developed CVD, 19.8% HTN, 13.7% proteinuria & 0.6% ESKD; corresponding rates in donors with FMD were 13.3, 22.2 & 20.6%, and none developed eGFR <30mL/min or ESKD. Donors with FMD vs without FMD, were more likely to develop proteinuria (20.6 vs 13.7%) (P=0.04).
However, in the propensity matched analysis, no difference between the groups on any outcome, including proteinuria.
Multivariable risk of CV, HTN & reduced eGFR
Risk of mortality in donors with FMD was
0.64 (P=0.61) & of CVD was 1.04 (P=0.95). Risks of HTN, proteinuria, eGFR <60mL/min & eGFR <45mL/min were not elevated.
Discussion
Kidney donors who had FMD in the donated kidney were not more likely to develop HTN or adverse CV or renal diseases.
FMD may present with HTN & 35% may present with stroke or TIA secondary to carotid & vertebral artery dissection.
Once FMD diagnosis is made, onetime
head-to-pelvic vascular imaging with CT angiography is indicated.
Studies addressing outcomes of donors with FMD were small in size & short in follow-up.
Mayo Clinic data: out of 2250 donors, 38 had FMD & bilateral disease seen in 14 of these. After 16.6 years of follow-up, donors with FMD had similar BP & UP excretion to in donors without FMD; long-term recipient outcomes from FMD donors did not differ from that of non-FMD kidneys.
Donors with FMD were less likely to have the left kidney removed.
Donors with FMD had a single renal artery in the non-donated kidney in 78.8% of cases compared with 61.6% of donors without FMD (P=0.01) & 90% of kidneys donated by both groups had a single renal artery.
Donors with FMD older (an average 12yrs) than those without FMD; typically those with FMD tend to be middle-aged White female with a FH of HTN.
Donors with FMD more likely unrelated to recipients & more likely to be White.
Strengths
It is the largest series of kidney donors with FMD that has been studied & the longest follow-up.
Outcomes were ascertainable in the majority of donors.
Limitations
The extent of FMD (unilateral vs bilateral, unifocal vs multifocal) is not captured in the dataset.
No information about the centers’ approach to donors with FMD.
Possibly donors with FMD included in the analysis had mild disease; perhaps those with severe disease not allowed to donate.
No data on the outcomes of the recipients of the donated kidney.
====================
What is the level of evidence provided by this article?
Level III
Thank you
Introduction
This was an observational case control study looking at Kidney donors with Fibromuscular Dysplasia and compared to donors without fibromuscular dysplasia (FMD).
FMD is defines as a non-atherosclerotic disease of the arteries whose etiology is unknown. It can affect multiple vascular beds including renal, carotid, iliac, visceral and coronary. It commonly presents with hypertension and can also present with stroke if the carotids are affected. FMD is encountered in 2.0-6.6% of kidney donors during evaluation of renal vasculature. There is limited data as to how a transplant center should approach a potential kidney donor with FMD
Methodology
Data was obtained from the RELIVE study that studied donor outcomes from 3 centers. They collected data for donors who had donated a kidney from the time period of 1963-2007.
A total of 8922 donors had donated a kidney from 1963-2007 out of which 113 had FMD and 8809 had no FMD. It was not clear how the 3 centers had selected the donors with FMD.
Donors with FMD were compared to propensity score matched donors with no FMD in a ratio of 1:4.
The participating study sites contacted the donors between 2010 and 2012.
The main outcomes were the development of:
Results
The donors were followed up for a mean period of 15.5 years.
Donors with FMD were more likely to be older (51 yrs vs 39 yrs), more likely to be women (80% vs 56%) and more likely to be Caucasian (90.3% vs 84.7%)
Baseline eGFR was also lower in donors with FMD (79 vs 88 mld/min/1.73m2. p < 0.001).
13.3% of donors with FMD developed CVD compared to 13.5% of donors without FMD
22.2% of donors with FMD developed HTN compared to 19.8% of donors without FMD.
No donor with FMD developed ESKD or GFR < 30 mls/min/1.73m2 compared to 0.6% of donors without FMD who developed ESKD
20.6% of donors with FMD developed proteinuria compared to 13.7% of donors without FMD (p=0.04)
However, in the propensity score matched analysis, there was no difference between the two groups on any of the outcomes studied including proteinuria.
These results demonstrate that kidney donors with FMD were not more likely to develop HTN or adverse CV or kidney outcomes.
Studies looking at outcomes of donors with FMD are sparse. One study from the Mayo Clinic looked at 38 kidney donors with FMD. After 16.6 years of follow up, donors with FMD had similar BPs and urine protein excretion compared to those observed in donors without FMD. Even the long term outcomes of kidney recipients with kidneys from donors with FMD did not differ from those who received kidneys from donors without FMD
Study Limitations:
Conclusion
Carefully selected kidney donors with FMD can safely donate.
Assessment of all vascular beds for the presence of FMD should be strongly considered when donors with FMD are considered for donation.
If donors with FMD are accepted for kidney donation, they should be evaluated at least annually for early detection of hypertension and signs of kidney function decline
Level OF Evidence
This is a case control study so the level of evidence is 3
Thank you
– Fibromuscular dysplasia (FMD) is a non-atherosclerotic arterial disease of unclear cause.
– It is characterized by abnormal cellular proliferation and disruption of the arterial wall structure, and is manifested by dissection, aneurysm and tortuosity of many vascular beds such as the renal, carotid, visceral, external iliac arteries and even the coronary arteries.
– FMD is encountered in 2.0–6.6% of kidney donors during evaluation of renal vasculature.
– There are limited data on how transplant canters approach donor candidates with FMD, and published transplant societies guidelines do not address this issue. Moreover, there are only a few case series that have addressed outcomes of donors with FMD.
– This is an observational retrospective cohort study comparing the development of HTN, CVD outcomes, proteinuria & GFR decline in donors with FMD & donors without FMD using The Renal and Lung Living Donor Evaluation (RELIVE) study which addressed long-term outcomes of 8922 kidney donors who donated between 1963 and 2007.
– It concluded that donors with FMD appear to do well with no increase in HTN, CVD, proteinuria or decline in GFR in comparison to non FMD donors, also that perhaps carefully selected donors with FMD can safely donate as long as affection of other vasculature beds are ruled out .
Level of evidence :
– Level 3 , observational retrospective cohort study
Thank you
Fibromuscular dysplasia (FMD) is a nonatherosclerotic systemic arterial disease that is discovered during kidney donor evaluation in 2.0–6.6%
This study compared the development of hypertension, cardiovascular disease (CVD), proteinuria and reduced estimated glomerular filtration rate (eGFR) in 113 kidney donors with FMD discovered during donor evaluation versus 452 propensity score matched donors without FMD.
Results
– Donors with FMD were older (51 versus 39 years), were more likely to be women (80% versus 56%)
– Donors with FMD had a higher systolic blood pressure at donation (124.7 versus 121.3 mmHg).
– After a mean follow-up of 15.5 6 8.9 years, a similar proportion of donors with and without FMD were alive, and developed hypertension (22.2% versus 19.8%), proteinuria (20.6% versus 13.7%) and CVD (13.3% versus 13.5%).
– No donor with FMD developed an eGFR < 30 mL/min/1.73 m2 or end-stage kidney disease.
These results demonstrate that kidney donors who had FMD in the donated kidney at the time of kidney donation were not at higher risk to develop hypertension or adverse cardiovascular or renal consequences. It is important to mention that recipients of FMD kidney were not at risk too of developing more renal complications.
This is a retrospective cohort study with level of evidence III
Thank you
Summarize the article:
Introduction:
Fibromuscular dysplasia (FMD) is a non-atherosclerotic arterial
disease with disruption of the arterial wall structure leading to dissection, aneurysm and tortuosity of many visceral arteries.
it is encountered in 2-6.6% of kidney donors
Material and method:
The Renal and Lung Living Donor Evaluation (RELIVE) study evaluated 8922 kidney donors from 1963–2007 duration.
The parameters evaluated were hypertension, CVD, decrease in eGFR and mortality.
There was follow-up of around 14.5 to 15.5 years
Results
There were 113 donors with FMS vs 8809 donors without FMD.
Donors with FMD were older, female and white donors.
Baseline eGFR was lower in donors with FMD
Open nephrectomy, right kidney donation and likelihood of the remaining kidney having just one artery were significantly higher in donors with FMD.
at follow-up, the incidence of hypertension, proteinuria, CVD and incidence of ESRD was similar in both the groups
Conclusion
Level of evidence: Level 3
Thank you
Will you consider FMD donors based on this paper?
Yes sir, I would accept donor with FMD after screening all vascular beds.
I would counsel the donor about strict post-donation follow-up for hypertension and renal function.
Thank you, do not forget to counsel the recipient as well.
Please summarise this article in your own words
Introduction
FMD is a non-atherosclerotic arterial disease. It is characterized by abnormal cellular proliferation and disruption of the arterial wall structure, and is manifested by dissection, aneurysm and tortuosity of many vascular beds such as the renal, carotid, visceral, external iliac arteries and even the coronary arteries
Outcome of FMD was addressed by a few studies. Most studies were small size with short duration of follow-up and the results were inconclusive
Aim of the study: study the outcome of HTN, CVD, proteinuria and reduced eGFR in kidney donors with FMD
Material and Methods
RELIVE study addressed the outcome of 8922 live kidney donors (1963to 2007). They compared the risk of HTN, CVD, proteinuria and low GFR in donors with FMD (n= 113) with matched donors with no FMD (n=425). The ratio was 1:4. Duration of follow-up was 14.5 (± 9.5) years for kidney donors with FMD and 15.5 (± 8.9) years for matched donors without FMD
Results
Donors with FMD were older, mostly women and with low Baseline eGFR
After a mean follow-up of 15.568.9years, 13.5% of donors without FMD developed CVD, 19.8% developed HTN, 13.7% developed proteinuria and 0.6% developed ESKD. The corresponding proportions in donors with FMD were 13.3, 22.2 and 20.6%, and none developed eGFR <30mL/min or ESKD
Discussion
FMD affects the renal arteries (75%), carotid arteries (74%) and vertebral arteries (33%). Clinically, patients with FMD present with HTN and 35% may present with stroke or TIA secondary to carotid and vertebral artery dissection. These observations have led to the recommendation that once a FMD diagnosis is made, patients should have one-time head-to-pelvic cross-sectional vascular imaging with CT angiography
Data from Mayo Clinic, from 2250 donors who presented for donation, 38 had FMD and in whom bilateral disease was encountered in 14. After 16.6years of follow-up, donors with FMD had similar blood pressure and urinary protein excretion to those observed in donors without FMD
Strengths and Limitations: the strength was large size kidney donors. Limitations were
1.. Extent of FMD (unilateral versus bilateral, unifocal versus multifocal) is not captured in the dataset
2. There is no information about the approach to donors with FMD (donors included possible were mild disease and severe disease excluded)
Conclusion
No increase risk of HTN, CVD, proteinuria or redued eGFR in donors with FMD when compared with matched donor without FMD. This may provide a justification for kidney donation in selected cases with FMD. Assessment of all vascular beds for the presence of FMD should be strongly considered when donors with FMD are considered for kidney donation
What is the level of evidence provided by this article?
Level 2 (retrospective cohort study)
Thank you
Will you consider FMD donors based on this paper?
I agree, it is a retrospective cohort study, but it is level 3.