Benefits of Renal Transplantation over Dialysis

Introduction The incidence of CKD is increasing most rapidly in people ages 65 and older The incidence of recognized CKD in people ages 65 and older more than doubled between 2000 and 2008. Adopted from NIDDK

ESRD Incident Rate After steady rise from 1980 to 2001, the incident rate of ESRD leveled off, although the number of ESRD prevalent cases continues to rise by about 21,000 cases per year Adopted from NIDDK

ESRD Incident Rates by Race ESRD incident rates are three times higher for African Americans than for Caucasians. ESRD rates in African – Americans (AA) rose more quickly than rates for all other races AA are about 3.5 times more likely to develop ESRD than Caucasians. Adopted from NIDDK

The financial aspects of ESRD/RRT Yearly costs for treating a patient on HD are nearly triple the costs for treating a transplant patient. ( HD/PD/TX/all ESRD) Adopted from NIDDK

Recipients of a Kidney Transplant Have a Longer Life Expectancy Than Patients Who Remain on Dialysis Transplantation remains a treatment of choice in selected group of pre-dialysis and dialysis patients and offers clear patient survival benefit when compared to dialysis, irrespective of the age group and comorbidities leading to ESRD. Expected remaining lifetime for recipients of a kidney transplant compared with patients on dialysis (across sexes and various races)a Recipients of a Kidney Transplant Have a Longer Life Expectancy Than Patients Who Remain on Dialysis This slide shows the years of expected remaining lifetime for patients on dialysis (orange bars) compared with recipients of a kidney transplant (blue bars) in 5-year age increments Based on estimates from 2012, recipients of a kidney transplant, regardless of age, can expect to have about 2.5 times more remaining years of life compared to patients on dialysis Similar trends were observed across genders and various races Reference: United States Renal Data System (USRDS). 2014 ADR chapters. http://www.usrds.org/2014/view/default.aspx. Accessed February 11, 2016. Based on estimates from 2012, recipients of a kidney transplant had about 2.5 times more remaining years of life than patients on dialysis a Data are from the United States Renal Data System (USRDS) 2014 Annual Data Report; estimates are from 2012. USRDS. 2014 ADR chapters. http://www.usrds.org/2014/view/default.aspx. Accessed February 11, 2016.

Patients With Certain Cancers Have a Better Chance of Surviving 5 Years After Diagnosis Than Patients Starting on Dialysis Death rate of patients on dialysis at 5 years compared with patients with selected solid tumor cancers (all stages)1,2,a Patients With Certain Cancers Have a Better Chance of Surviving 5 Years After Diagnosis Than Patients Starting on Dialysis This slide compares the number of people on dialysis who died within 5 years of starting dialysis with the 5-year death rate at diagnosis for patients with selected solid tumor cancers, across all stages1,2 Approximately 60 out of every 100 patients who began dialysis in 2007 died within 5 years of starting dialysis1 This was higher than the 5-year death rate for people who were diagnosed with any stage of2: Prostate cancer (1 out of every 100 patients) Melanoma of the skin (9 out of every 100) Breast cancer in females (11 out of every 100) Kidney cancer (28 out of every 100) Colon and rectal cancers (35 out of every 100) But was lower than the 5-year death rate for people who were diagnosed with any stage of2: Stomach cancer (72 out of every 100) Lung cancer (83 out of every 100) Liver cancer (83 out of every 100) Pancreatic cancer (93 out of every 100) References: USRDS. 2014 ADR chapters. http://www.usrds.org/2014/view/default.aspx. Accessed February 11, 2016. American Cancer Society (ACS). Cancer facts & figures 2015. http://www.cancer.org/acs/groups/content/@editorial/documents/document/acspc-044552.pdf. Accessed March 1, 2016. a Dialysis mortality data are taken from the USRDS 2014 Annual Data Report; cancer mortality data are from the American Cancer Society (ACS) Cancer Facts & Figures 2015. 1. USRDS. 2014 ADR chapters. http://www.usrds.org/2014/view/default.aspx. Accessed February 11, 2016. 2. ACS. Cancer facts & figures 2015. http://www.cancer.org/acs/groups/content/@editorial/documents/document/acspc-044552.pdf. Accessed March 1, 2016.

Mortality risks in two groups of cadaveric renal transplant recipients relative to wait-listed dialysis patients. Mortality risks in two groups of cadaveric renal transplant recipients relative to wait-listed dialysis patients. OJO A O et al. JASN 2001;12:589-597 ©2001 by American Society of Nephrology

How long do patients have to wait for a kidney from a deceased donor? What are the benefits of receiving a kidney from a living donor vs a kidney from a deceased donor? ? [Note to speaker: These 2 questions can be used to engage your audience and provide an opportunity for discussion or to introduce the following 2 slides that describe waiting times for a deceased donor kidney and the benefits of receiving a kidney from a living donor vs a deceased donor.] Review slide as stated

Patients Who Receive a Kidney Transplant Have a Longer Life Expectancy Than Those Who Remain on Dialysis; However, the Wait for a Kidney From a Deceased Donor Is Long The median waiting time for a deceased donor kidney transplant was 4 years for adult patients active at listing in 2009 Patients Who Receive a Kidney Transplant Have a Longer Life Expectancy Than Those Who Remain on Dialysis; However, the Wait for a Kidney From a Deceased Donor Is Long This slide highlights the long wait times for a kidney transplant from a deceased donor1,2 The median waiting time for a deceased donor kidney transplant was 4 years for adult patients active at listing in 20091 Only 1 out of 5 (22.27%) adult patients who were newly placed on the waiting list in 2010 received a kidney from a deceased donor within 3 years2 Of the adult patients who were newly wait-listed in 2010, 63% did not receive a kidney transplant within 3 years2 This number includes: 44% of patients who were still waiting 9% of patients who were removed from the list 9% of patients who died Factors affecting how long you wait include how well you match with the donor, how sick you are, and how many donors are available in your local area compared with the number of patients waiting3 References: Matas AJ, Smith JM, Skeans MA, et al. OPTN/SRTR 2013 annual data report: kidney [supplementary information; Table KI 1.11]. Am J Transplant. 2015;15(suppl 2):1-34. http://onlinelibrary.wiley.com/doi/10.1111/ajt.13195/suppinfo. Accessed March 1, 2016. Matas AJ, Smith JM, Skeans MA, et al. OPTN/SRTR 2013 annual data report: kidney [supplementary information; Table KI 1.10]. Am J Transplant. 2015;15(suppl 2):1-34. http://onlinelibrary.wiley.com/doi/10.1111/ajt.13195/suppinfo. Accessed March 1, 2016. United Network for Organ Sharing (UNOS). Frequently asked questions. https://www.unos.org/transplantation/faqs/. Accessed February 11, 2016. 63% of patients placed on the waiting list in 2010 did not receive a kidney transplant within 3 yearsb a Data are from the Organ Procurement and Transplantation Network/Scientific Registry of Transplant Recipients (OPTN/SRTR). 2013 Annual Data Report: Kidney. Three-year outcomes are for adult patients waiting for a kidney transplant and first placed on the waiting list in 2010. b Includes patients who were still waiting, died, or were removed from the list. Matas AJ et al. Am J Transplant. 2015;15(suppl 2):1-34 [supplementary material]. http://onlinelibrary.wiley.com/doi/10.1111/ajt.13195/suppinfo. Accessed March 1, 2016.

Aprox. 7K patients die/yr while being waitlisted. The waiting list continues to grow, with a 4 percent increase in 2011; 86%were awaiting their first transplant, and 14 % were awaiting a re-transplant. Aprox. 7K patients die/yr while being waitlisted. The probability of first-year all-cause graft failure (return to dialysis or death with a functioning transplant) for DDKT recipients continued to improve in 2010, reaching 8.5 percent. The incidence of acute rejection during the first year post-transplant, reported in 10 percent of deceased and living donor recipients in 2010, has declined more than 50 percent since 2000, but has remained stable in the past five years. Among recipients who died with a functioning transplant during 2007–2011, cardiovascular disease was reported as the leading cause of death, accounting for 31 percent of these deaths, followed by infectious causes and malignancies at 19 and 10 percent, respectively. USRDS 2013

EARLY TRANSPLANT REFFERAL Pre-emptive transplantation has been shown to improve post transplant graft and recipient survival Pre-emptive transplant likely reduces cardiovascular and infectious consequences of long-term dialysis

Meier-Kriesche HU1, Kaplan B. Transplantation Meier-Kriesche HU1, Kaplan B. Transplantation. 2002 Nov 27;74(10):1377-81.

Demographics of KTx recipients

Types of kidney donation Living donation Live donor paired exchange/SWAP Standard Criteria Donor Extended Criteria Donor (ECD) kidneys/KDPI Donation after Cardiac Death (DCD) kidneys CDC High Risk Donor (PHE)

Standard criteria donor (SCD) versus extended criteria donor (ECD) By initial definition, rate of graft failure of ECD is 1.7 times that of SCD Donation after cardiac death (DCD) kidneys are noted with: More delayed graft function (prolonged WIT) Long-term graft survival comparable to SCD

ORIGINAL ARTICLE Transplantation of Kidneys from Donors Whose Hearts Have Stopped Beating Cho y.et al. NEJM 1998;338:221-225

Outcomes with ECD kidneys Shorter graft survival Higher risk of delayed graft function Shorter waiting time Increased patient survival for diabetics and older recipients (groups with the highest death rates on dialysis)

1-, 5-, and 10-year patient and graft survival rates A Kidney Transplant From a Living Donor Results in Better Long-term Outcomes Than a Transplant From a Deceased Donor or Dialysis 1-, 5-, and 10-year patient and graft survival rates Patient survival ratesa Donor kidney survival ratesa A Kidney Transplant From a Living Donor Results in Better Long-term Outcomes Than a Transplant From a Deceased Donor or Dialysis The graph on the left side compares 1-, 5-, and 10-year survival rates for patients on dialysis, recipients of a deceased donor kidney, and recipients of a living donor kidney Based on 1-year data from 2011, 5-year data from 2007, and 10-year data from 2002, patients on dialysis (orange bars) had the lowest 1-, 5-, and 10-year survival rates—78.8%, 40.5%, and 18.6%, respectively Recipients of kidneys from living donors had the highest long-term survival rates. Survival rates at 5 and 10 years were 84.8% and 52.1%, respectively, for recipients of a kidney from a living donor The graph on the right side compares the 1-, 5-, and 10-year survival rates for kidneys transplanted from deceased donors and living donors Based on 1-year data from 2011, 5-year data from 2007, and 10-year data from 2002, kidneys transplanted from living donors had higher long-term (5- and 10-year posttransplant) survival rates compared with kidneys transplanted from deceased donors 5-year survival rates of kidneys from living donors (blue bars) and deceased donors (gray bars) were 82.9% and 70.5%, respectively 10-year survival rates of kidneys from living donors (blue bars) and deceased donors (gray bars) were 58.6% and 43.4%, respectively Reference: USRDS. 2014 ADR chapters. http://www.usrds.org/2014/view/default.aspx. Accessed February 11, 2016. a Data are from the USRDS 2014 Annual Data Report; 1-year data are from 2011, 5-year data are from 2007, and 10-year data are from 2002. USRDS. 2014 ADR chapters. http://www.usrds.org/2014/view/default.aspx. Accessed February 11, 2016.

Advantages of living donor kidneys Short or no waiting time, vs. 2-7 year wait Donors are healthier Shorter cold ischemia, less DGF and less rejection Elective Sx better than emergency surgery Better allograft function at baseline

What are the potential risks associated with living kidney transplantation? [Note to speaker: This question can be used to engage your audience and provide an opportunity for discussion or to introduce the next slide that describes some of the risks that kidney transplant recipients and living kidney donors may face.] Review slide as stated

Kidney Transplant Recipients and Live Kidney Donors May Face Risks Recipient risks1 Donor risks2 What are Blood clots Infections Kidney failurea Kidney rejectiona Death Side effects from immunosuppressive medications such as: Heart attack or stroke Cancer High blood pressure High blood sugar High cholesterol Surgical complications such as: Pain Infection Blood clots Death Long-term risks such as: High blood pressure Hernia Reduced kidney function Higher risk of end-stage kidney diseaseb Kidney Transplant Recipients and Live Kidney Donors May Face Risks The risks associated with kidney transplantation and living donation must not be overlooked This table lists some of the risks and complications that living kidney donors and recipients may face [Note to speaker: Click to review some of the risks that recipients of a kidney transplant may face.] Remind the audience that in some instances, a recipient of a kidney transplant may experience kidney failure or rejection, which may require going back on dialysis1 [Note to speaker: Click to review some of the risks that living donors of a kidney may face.] Review the risks to living donors of a kidney as stated The risk of death within 3 months of donating a kidney is small, but not 0. In a national study of more than 80,000 living donors of a kidney between 1994 and 2009, about 1 in 3225 donors died within 3 months of donation2  Reduced kidney function may lead to dialysis or transplantation3 Review callout as stated    References: National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Kidney failure: choosing a treatment that’s right for you. http://www.niddk.nih.gov/health-information/health-topics/kidney-disease/kidney-failure-choosing-a-treatment-thats-right-for-you/Documents/choosingtreatment_508.pdf. Published November 2007. Accessed March 9, 2016. Segev DL, Muzaale AD, Caffo BS, et al. Perioperative mortality and long-term survival following live kidney donation. JAMA. 2010;303(10):959-966. UNOS. Living donation. https://www.unos.org/donation/living-donation/. Accessed February 25, 2016. These are not all the risks associated with kidney transplantation. Speak to your transplant team/health care professional about the potential risks associated with donating or receiving a kidney a In some instances, a recipient of a kidney transplant may experience kidney failure or rejection, which may require going back on dialysis.3 b Reduced kidney function may lead to dialysis or transplantation. 1. MedlinePlus; US National Library of Medicine. https://www.nlm.nih.gov/medlineplus/ency/article/003005.htm. Updated June 29, 2015. Accessed November 9, 2015. 2. United Network for Organ Sharing (UNOS). Living donation. https://www.unos.org/donation/living-donation/. Accessed February 25, 2016. 3. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Kidney failure: choosing a treatment that’s right for you. http://www.niddk.nih.gov/health-information/health-topics/kidney-disease/kidney-failure-choosing-a-treatment-thats-right-for-you/Documents/choosingtreatment_508.pdf. Published November 2007. Accessed March 9, 2016.

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