Reducing barriers to living donor kidney transplantation ... · Cumulative BPAR probability History...

Reducingbarrierstolivingdonorkidneytransplanta5oninOntario–adap5ngtheExploreTransplantEduca5onProgram

IstvanMucsiUniversityHealthNetwork,Toronto,Ontario,

Canada

Email:istvan@nefros.net

2016-06-17 RenalTransplantSymposium2016

Disclosure

•  TheExploreTransplantOntarioadaptaDonprojectreceivedunrestrictededucaDonalsupportfromAstellasPharmaCanada

2016-06-17 RenalTransplantSymposium2016

•  Whykidneytransplant;whylivingdonorkidneytransplant–DOWEHAVEAPROBLEM??

•  PotenDallymodifiablebarrierstoKTandLDKT–  Psychosocialbarriers–  Ethnoculturalbarriers

•  HelpingpaDentsconsidertransplant–educa5on–ExploreTransplant

•  AdapDngExploreTransplant–ExploreTransplantOntario

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CST Consensus Guidelines on Kidney Transplant, CMAJ 2005

CMAJ•November8,2005•173(10)|

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hQp://ichoosekidney.emory.edu/

(TransplantaDon2016;100:630–639)

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hQp://ichoosekidney.emory.edu/

(TransplantaDon2016;100:630–639)

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ProjectedlifeexpectancyaTerESRDonsetbyrecipientageandtreatmentmodality.

Schold J D , and Meier-Kriesche H CJASN 2006;1:532-538

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AmericanJournalofTransplanta5on2008;8:58–68

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Ø  Accordingtothelatestavailabledata,90.8%and81.4%ofkidneystransplantedintoadultsfromlivinganddeceaseddonors,respecDvely,weres5llfunc5oningatleast5yearsaTertransplant.

Ø  Accordingtothelatestavailabledata,43.2%ofpa5entsondialysistreatmentssurvivedatleast5years(8398pa5ents).

Ø  WL=3,377pa5ents

Ø  Ofthe20,690paDentsondialysis,morethanthree-quarterswerereceivinginsDtuDonalhemodialysis,themostexpensivetreatmentopDon

NumberofKidneyTransplantsbyDonorType,Adult(18+),2005to2014

Source: Canadian Organ Replacement Register, 2015, CIHI

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Deceased 572 689 727 713 731 725 758 809 807 806 Living 411 461 458 453 441 466 438 435 484 434

0

100

200

300

400

500

600

700

800

900

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Adult(18+)LivingDonorKidneyTransplantsbyYearandProvince,2005to2014

Source: Canadian Organ Replacement Register, 2015, CIHI

0

50

100

150

200

250

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Ont.

B.C.

Alta.

Que.

N.S.

Man.

Sask.

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Lancet2015;385:2003–13

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AmericanJournalofTransplanta5on2014;14:1562–1572

AmericanJournalofTransplanta5on2014;14:1562–1572

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Cases

•  68yoinuitmale,livinginMox18mosonHD–potenDallivedonor;T2DM,PVD,CAD

•  65yomale,onHD;t2dm,HCV–failedIFN;

•  35yocreefemale;onHDx1yr;T2DM,BMI38

•  68yomaleonHDx2yrs;T2DM,CAD,BMI41;AC145cm;

•  38yoAAfemaleonHDx18mos;SSD;stroke4mosago;OFO

•  40yoAAfemale,onHDx3yrs;HIV+;previousinfs;

•  Recurrentproblemswithnon-adherencetodialysis,drugseekingbehavior,useofrecr.drugs,narcoDcanalgesics

•  Non-adherencetoHD,no-showforseveralappointments

•  35yo,AfricanCanadianmale•  ESKDduetoGN•  OnPDx3yrs,recentlyswitchedtoHD•  NomajorcomorbidiDes•  Liveswithcommonlawpartner,stablerelaDonship

•  Pt.wasdeclinedtobewaitlisted–heaccepted

MsC–15oct

•  61yoF•  ESKD,typ1DM•  PDsince2009•  T1DM,HTN,DLP•  ReDnopathy,neuropathy,

gastroparesis•  CAD,AMI2002•  AMI2010,PCI•  CABG2012

•  ECD15oct•  IGF•  NSTEMIpostop•  D/CwithcreatN

MrT–15oct•  77yoAAM•  ESKDsince2011•  T2DM,HTN•  CAD–noMI•  ReDnopathy–legallyblind•  GERD•  ProstateCA–

prostatectomyin2006•  Liveswithyoungerwife•  Goodsupport•  Wantstobefreefrom

dialysis,wantstotravel

•  ECD/DCD15oct•  DGF•  d/cwithcreat200,

declining

Someongoingissues,creatcca160,saysitisbeiernowthanbefore;madehisfirsttriptovisiDngfamilyinFloridainApril

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OnewordofcauDon:increasingkidneytransplantaDonandlivingdonorkidneytransplantaDon

Increasingtherecipientanddonorpool

Thiscannotbesuccessfulwithoutrethinkingandimprovingpost-transplantandpost-dona5oncare

SAFELY

SAFELY

Psychosocialbarriers

•  MentalHealthissuesarefrequentinpaDentswithEndStageRenalDisease–  ~40%ofpaDentsondialysisexperiencedepression(Szeifert2011,

Cukor2007)•  Associatedwithmortalityandpoorqualityoflife(KimmelPL2000,LopesAA2002)

–  RelaDvelyneglected–  MaybeapotenDalbarriertotransplantaDon

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CourtesyofG.Rodin

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NephrolDialTransplant(2012)27:2107–2113

35-45%ofWLpaDentshadhighriskofdepression

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!

Univariablehazardra5o(95%CI):0.81(0.70,0.93)

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ReferraltotransplantWUcomple5on,byhistoryofpsychiatricdisorders

Mul5variableadjustedlikelihoodofcomple5ngthetransplantWUwithintwoyearsaTerreferralforpa5entswiththe

historyofpsychiatricdisordersornon-adherence

MentalHealth HazardRa5o(95%C.I.)HistoryofPsychiatricdisorder(Yesvs.No) 0.81(0.70,0.95)

Adjustedfor:age,sex,maritalstatus,EnglishcommunicaDon,race,OntarioMarginalizaDonIndexandthehistoryof:historyofdiabetes,coronaryarterydisease/myocardialinfarcDon,heartfailure,strokeandperipheralvasculardisease,chroniclungdisease,ornon-skincancer2016-06-17 RenalTransplantSymposium2016

Log Rank P = 0.15

0.00

0.10

0.20

Cum

ulativ

e BP

AR p

roba

bility

207 183 175 169 160 150 139History of MH disorders748 676 656 642 601 556 512No history of MH disorders

Number at risk

0 4 8 12 16 20 24

Months post-transplant

History of MH disordersNo history of MH disorders

Biopsy-provenacuterejec5onbyhistoryofMH

Log Rank P = 0.04

0.00

0.10

0.20

Cumu

lative

BPA

R pr

obab

ility

108 97 92 90 78 72 63History of non-adherence847 762 739 721 683 634 588No history of non-adherence

Number at risk

0 4 8 12 16 20 24

Months post-transplant

History of non-adherenceNo history of non-adherence

Biopsy-provenacuterejec5onbyhistoryofNA

Mul5variableadjustedlikelihoodofBPARforpa5entswithahistoryofMHorNAVariables HazardRa5o

(95%C.I.)Historyofmentalhealthdisorder(YesversusNo) 1.31(0.87,1.99)

Historyofnon-adherence(YesversusNo) 1.26(0.76,2.09)

Adjustedfor:age,sex,race,donortype,ECD,DGF,HLAmismatchandhistoryofdiabetes

Log Rank P = 0.72

0.00

0.20

0.40

0.60

0.80

1.00

Cum

ulativ

e to

tal g

raft

failu

re

207 196 162 124 92 66 40 24 11History of MH disorders748 708 573 469 367 267 195 131 78No history of MH disorders

Number at risk

0 12 24 36 48 60 72 84 96

Months post-transplant

History of MH disordersNo history of MH disorders

TotalgraTfailurebyhistoryofMH

Log Rank P = 0.24

0.00

0.20

0.40

0.60

0.80

1.00

Cum

ulativ

e to

tal g

raft

failu

re

108 102 76 55 38 18 8 5 2History of non-adherence847 802 659 538 421 315 227 150 87No history of non-adherence

Number at risk

0 12 24 36 48 60 72 84 96

Months post-transplant

History of non-adherenceNo history of non-adherence

TotalgraTfailurebyhistoryofNA

Mul5variableadjustedlikelihoodofTGFforpa5entswithahistoryofMHorNA

Variables HazardRa5o(95%C.I.)

Historyofmentalhealthdisorder(YesversusNo) 0.96(0.56,1.64)

Historyofnon-adherence(YesversusNo) 1.65(0.89,3.08)

Adjustedfor:age,sex,race,donortype,ECD,DGF,HLAmismatchandhistoryofdiabetes

Ethnoculturalbarriers

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AmericanJournalofTransplanta5on2013;13:1557–1565

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KidneyInternaDonal(2007)72,499–504;

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PLOSONE|DOI:10.1371/journal.pone.0124321July31,2015

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Race/ethnicity–accesstotransplant,LDKT

Log Rank P < 0.001

0.00

0.25

0.50

0.75

1.00

Cum

ulat

ive tr

ansp

lant

atio

n pr

obab

ility

524 406 237 106 38Other/unknown143 82 45 29 9Indo Asian164 116 53 25 6East Asian182 119 68 36 18Black756 395 201 100 42White

Number at risk

0 2 4 6 8Years from referral date

WhiteBlackEast AsianIndo AsianOther/unknown

Transplant LDKT

Log Rank P < 0.001

0.00

0.25

0.50

0.75

1.00

Cum

ulat

ive tr

ansp

lant

atio

n pr

obab

ility

524 406 237 106 38Other/unknown143 82 45 29 9Indo Asian164 116 53 25 6East Asian182 119 68 36 18Black756 395 201 100 42White

Number at risk

0 2 4 6 8Years from referral date

White BlackEast Asian Indo AsianOther/unknown

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LDtransplantversushavingapoten5alLDatreferral

Psychosocialandethno-culturalbarrierstolivingdonorkidneytransplanta5on

I.Mucsi,A.D.Waterman,S.J.Kim,J.S.Zaltzman,K.P.Fung,D.Buchman,R.NissimandM.

Novak

ThisstudywillinvesDgatereadinesstoacceptlivingdonorkidneytransplant(LDKT)andalsopsychosocialandethno-culturalbarrierstoaccepDngLDKTamongpaDentswithchronickidneydisease(CKD)–referredforpre-transplantassessment

ASSESSINGPATIENTREPORTEDMEASURES

CAPTURINGTHEPATIENTPERSPECTIVE

Study Questionnaires •  TRANSPLANTDECISIONMAKINGSURVEY•  ILLNESSINTRUSIVESNESSRATINGSCALE•  EXPERIENCEOFCLOSERELATIONSHIPSCALE•  KIDNEYDISEASEQUALITYOFLIFE•  FATIGUESEVERITYSCALE(FSS)•  MOSSOCIALSUPPORT•  SHORTLITERACYSURVEY•  SOCIO-DEMOGRAPHIC&CULTURALQUESTIONNAIRE•  PATIENTRESPONSEQUESTIONNAIRE•  DART(PHQ-9,GAD,ESAS,SDI)

Didyoufindthetaskofcomple5ngtheques5onnairesONTHETABLETCOMPUTERtoodifficultor5ring?

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No Yes

%

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Notatall Veryliile Somewhat Agreatextent

Someonecompletedit

forme

%

Didyouneedsomeone’shelptocompletetheques5onnaire?

Sample Question from DART (PHQ-9,GAD,ESAS,SDI)

Propor5onofpa5entswithdistress(n=64)

0102030405060708090

100

Depression Anxiety SocialdifficulDes Anydistress

%

Factorsassociatedwithdistress(any)

Txknowledgevshavingalivingdonoriden5fied

0%

20%

40%

60%

80%

100%

Txknowledge

low

Txknowledge

high

LDyes

LDno

0%

20%

40%

60%

80%

100%

Txknowledge

low

Txknowledge

high

LDlate

LDearly

% %

TxknowledgevsLDreadiness

TxknowledgevsLDdonoriden5fied

Reducingbarrierstolivingdonorkidneytransplanta5oninOntario–adap5ngtheExploreTransplantEduca5onProgram

RoadtoTransplantRequires:

•  LearnabouttransplantasanopDon

•  BeginevaluaDon–  (beidenDfiedandaccept)

•  Aiendtransplantappointments

•  Getlistedfortransplant•  Completeyearlyre-evaluaDon•  Findamatchingkidney•  Receiveadeceasedorlivingdonortransplant

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JAmSocNephrol25:ccc–ccc,2014.doi:10.1681/ASN.2013121298

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ClinJAmSocNephrol▪:ccc–ccc,2015.doi:10.2215/CJN.00950115

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TransplantaDon2014;00:00Y00

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Transplant Education Practices in Dialysis Centers

Providers engaging in this practice:

(N=1544)

Orally recommend patients learn more about transplant themselves 72%

Orally recommend being evaluated for transplant 69%

Refer patients to an external transplant educational program 44%

Distribute transplant center phone numbers 37% Detailed discussion about advantages/risks of DDKT 21% Detailed discussion about advantages/risks of LDKT 21%

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WhatisExploreTransplant?

§  Comprehensive education program that helps kidney patients make informed transplant decisions §  Video, print resources with patient and

donor stories §  Discussion of risks/benefits of transplant

and living donation §  Individually-tailored conversations

based on what is important to patient §  Educational materials for dialysis patients,

family members & living donors

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• Review,updateandadaptExploreTransplantcontenttoCanadianhealthcaresystem

•  IncludeOntariophysicians,paDentsandlivingdonorsinvideos

ExploreTransplant–

OntarioAdapta5on

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Engagementfromall6Ontariotransplantprograms

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Nextsteps

•  Pilottraining–MAY10,UHN

•  PilotstudyofETO–MSH-UHNAMOInnova5onfund

•  ProvincialimplementaDonstudy(Dr.A.Garg)ofamulDfacetedintervenDontoincreaselivingdonorkidneytransplant–SPOR-CAN-SOLVED-CKD

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Alsospecialthankstothedialysisandtransplantprofessionalsfortheircontribu5onfrom:

•  KidneyFoundaDonofCanada

•  KingstonGeneralHospital,Kingston,Ontario

•  LondonHealthSciencesCentre,London,Ontario

•  St.Joseph`sHealthcare,Hamilton,Ontario

•  St.Michael`sHospital,Toronto,Ontario

•  TheOiawaHospital,Oiawa,Ontario

•  UniversityHealthNetwork,Toronto,Ontario

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2016-06-17 RenalTransplantSymposium2016

Specialthanksfortheirhelpwiththemanagementoftheproject:

•  Ms.DorothyWong•  Ms.HeatherFord•  Ms.RitaKruger•  Ms.WilmaAranha•  Mr.BasdeBeer•  Mr.AlexanderGluhushkinandMr.AnthonyOlsen•  Studentsofmyresearchteam

2016-06-17 RenalTransplantSymposium2016

Specialthanksto:

•  Aarushi Bansal•  Amanda Sissons•  Candice Richardson•  Dmitri Belenko•  Eleanor Warsmann •  Evan Tang•  Eszter Mucsi•  FranzMarie Gumabay•  Kefan Bei•  Luca UgenD•  Luke Dingwell•  Michael Jeanneie•  Nathaniel Edwards•  Priscilla Yung•  Sarah Cao•  Yalinie Kulandaivelu

Dr.S.J.Kim,Ms.YanhongLi,Mr.OlusegunFamureMs.DorothyWong Ms.HeatherFordCurrentandpaststudentsinmygroup:

2016-06-17 RenalTransplantSymposium2016