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Tag: Kidney Transplant

  • Hot climates worsen chronic kidney disease outcomes

    Hot climates worsen chronic kidney disease outcomes

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    Chronic kidney disease patients living in the hottest countries experienced an additional 8% drop in kidney function each year compared to those living in temperate climates, finds a new study from researchers at UCL and the London School of Hygiene & Tropical Medicine (LSHTM).

    The study, published in The Lancet Planetary Health, is the first global, medium-term analysis of the relationship between chronic kidney disease and heat. The results suggest that heat is a clinically important factor in poorer outcomes for kidney patients in hot countries, regardless of whether the country was high- or low-income and other health variables such as diabetes. 

    Chronic kidney disease (CKD), which describes kidney problems due to a range of causes, often leads to a gradual loss of kidney function over time and affects one in ten people worldwide. Once a patient’s kidneys no longer work well enough to keep them alive, kidney replacement therapy – dialysis or a kidney transplant – is required.

    While the cost of treating individuals with CKD is relatively low, kidney replacement therapies are hugely expensive and reduce the patient’s quality of life. Kidney failure alone accounts for around 3% of the NHS’s budget, with dialysis costing £30-40,000 per person each year. Currently, around 70,000 people receive kidney replacement therapy in the UK, with around 45% on dialysis and 55% with functioning kidney transplants.

    In less developed countries, these therapies are often unavailable – meaning kidney failure is fatal.

    It has long been known that patients with CKD fare badly in many hot countries. But whether heat makes CKD progress more rapidly has been a difficult question to answer, due to differing rates of underlying kidney disease and other health issues, varying access to medical care in different regions, as well as the need to collect standardized data from patients while they are otherwise well.

    In this study, researchers at UCL and LSHTM compared CKD clinical trial data, provided by AstraZeneca, to heat index data to assess whether high levels of heat exposure corresponded to changes in kidney function in patients with CKD. This included 4,017 individuals in 21 countries, representing a wide range of climates as well as a mix of middle- and high-income nations.

    The analysis showed that patients living in very hot climates had an additional 8% decline in kidney function each year compared to those living in temperate climates. There was no difference in the association between heat and kidney function according to national income or whether a patient was overweight, had high blood pressure or had diabetes.

    We already knew individuals with kidney disease have worse outcomes in many hot, poor countries around the world. But until now it’s been impossible to say whether temperature and humidity are important drivers of disease progression or whether this was accounted for by access to quality healthcare, living conditions, diet, diabetes and a whole host of other factors.


    Our findings suggest that heat exposure itself, at levels experienced by individuals living in the hotter parts of the world, does cause kidney function to deteriorate more rapidly in those with pre-existing chronic kidney disease and to a degree that is meaningful for patients.


    Clearly, this is concerning given that the planet is getting hotter due to climate change. But now that the evidence suggests heat is important, we can test interventions to do something about it, whether this is through hydration, avoiding direct sun exposure or other measures to combat the effects of extreme heat.”


    Professor Ben Caplin, senior author of the study from UCL Division of Medicine

    As the study only looked at patients with CKD, the results do not provide insights into the relationship between heat and kidney function in people with normal kidneys.

    Professor Dorothea Nitsch, a senior author of the study from the London School of Hygiene & Tropical Medicine, said: “The hot countries in our study vary in terms of economic status, from wealthy countries like the US and Japan to middle-income countries like Vietnam, but our findings were not explained by GDP. Access to measures such as air conditioning and readily available drinking water, which could be used to help reduce the impact of heat, are not always accessible to patients.”

    Global heating is a growing threat to people and the planet. The average surface temperature is now 1.1 C hotter than it was before the Industrial Revolution. Scientists say that the world must keep this rise to 1.5 C in order to maintain a liveable climate and avoid the worst climate impacts, yet current progress on reducing carbon emissions would see an increase of 3 C by 2100.

    Professor David Wheeler, a senior author of the study from UCL Division of Medicine, said: “Ultimately, our findings indicate that patients with chronic kidney disease in hot countries are more likely to end up on dialysis or require a kidney transplant, both of which are life-saving but also impact quality of life and are expensive where available.

    “Unfortunately some of the hottest countries are also those where kidney replacement therapies are not available, which is a huge concern for individuals and public health systems.”

    The DAPA-CKD trial was funded by AstraZeneca.

    Source:

    University College London

    Journal reference:

    Zhang, Z., et al. (2024) Ambient heat exposure and kidney function in patients with chronic kidney disease: a post-hoc analysis of the DAPA-CKD trial. The Lancet Planetary Health. doi.org/10.1016/S2542-5196(24)00026-3.

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  • Focusing on rare conditions could reduce kidney disease burden

    Focusing on rare conditions could reduce kidney disease burden

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    Focusing on rare conditions could significantly reduce the burden of kidney disease on both patients and the NHS, according to a major new study led by UCL and the UK Kidney Association.

    The study, published in The Lancet to mark World Kidney Day, draws on the largest rare kidney disease dataset ever created. It found that patients with rare kidney diseases are 28 times more likely to experience kidney failure than those with chronic kidney disease (CKD), but are less than half as likely to die before kidney failure treatment is needed.

    The results suggest that additional focus on treating rare kidney diseases, many of which have new therapies in development or already available, could disproportionately alleviate the overall demand for expensive and hazardous dialysis and kidney transplantation treatments. The authors hope that the research will reframe perceptions of chronic kidney disease, rare diseases and kidney failure among patients, caregivers, regulators, healthcare providers, and researchers.

    Chronic kidney disease (CKD) ranges from mild loss of kidney function to kidney failure with around 6% of the general population having mild to moderate CKD – most often caused by poorly controlled blood pressure or diabetes.

    Rare kidney diseases are a group of conditions that each affect fewer than one in 2,000 people. Though each disease might be rare on its own, collectively their impact is significant. Rare kidney diseases account for 5-10% of people with CKD, but they constitute over a quarter of those receiving dialysis or with a kidney transplant globally.

    To find out what happens to people with these difficult-to-study disorders, the UK’s National Registry of Rare Kidney Diseases (RaDaR) was set up in 2010. It continues to be developed and run by the UK Kidney Association and now includes over 25,000 patients with rare kidney diseases recruited from 108 UK hospitals.

    In this study, researchers from UCL and the UK Kidney Association charted the progression and outcomes in 28 rare kidney diseases by comparing data from 27,285 RaDaR patients with data from 2.81 million CKD patients in the general population.

    They found that over five years, rare kidney disease patients were 28 times more likely to experience kidney failure compared to CKD patients, yet their overall risk of death was less than half.

    Professor Danny Gale, senior author of the study from UCL Division of Medicine and Director of RaDaR, said: “This study underscores the importance of recognizing the pivotal role rare kidney diseases play in the overall burden of kidney failure. Our results show that rare diseases can progress from mild kidney damage to kidney failure so rapidly that, despite being rare in the population, they make a major contribution to the overall burden of kidney failure. This means that therapies effective in these diseases are likely to have a disproportionately beneficial impact on the overall demand for life-sustaining dialysis and kidney transplantation.

    “I hope that this will be a call to arms to show how important rare kidney diseases are and the many potential benefits of focusing on these conditions. Treatments for many of these diseases are either available or in development, so I think we now have a golden opportunity to substantially reduce the burden, both for patients and the NHS, of kidney failure.”

    The authors say that the results are likely to reframe perceptions of chronic kidney disease, rare diseases and kidney failure among regulators, healthcare providers and researchers.

    In general, rare kidney disease patients are much younger than those with CKD and are much less likely to die from related conditions such as cardiovascular disease. We know that they can live a long life with a successful kidney transplant, but there’s also an opportunity to prevent kidney failure in the first place with targeted treatment. I hope that the robust, large-scale data for each of the 28 diseases covered by RaDaR will inform trial design and make developing new treatments a less uncertain endeavor for drug companies.”


    Dr Katie Wong, first author of the study from UCL Division of Medicine and RaDaR Clinical Research Fellow at the UK Renal Registry

    As well as the difference new treatments would make to patients’ lives, reducing the burden of kidney failure could bring significant cost and resource savings. Kidney failure alone accounts for around 3% of the NHS’s budget, with dialysis costing £30-40,000 per person each year. Currently, around 70,000 people receive kidney replacement therapy in the UK, with around 45% on dialysis and 55% with functioning kidney transplants.

    Ron Cullen, Chief Executive of the UK Kidney Association, said: “Since its inception some 13 years ago, the National Registry of Rare Kidney Diseases (RaDaR) has been a key strategic development led by the UK Kidney Association and the renal community. It is now the largest rare kidney disease registry in the world and its continuous growth and evolution make it an invaluable resource.

    “With a strengthening connection between the medical community and patients with rare kidney diseases, RaDaR offers insights that are crucial for shaping future research and clinical discoveries. It is wonderful to see all the hard work of so many individuals come to fruition in a paper that could have significant patient benefit.”

    Elaine Davies, Director of Research Operations at Kidney Research UK said: “As well as highlighting the importance of finding treatments for rare kidney diseases, these new results will allow patients and doctors to make more informed decisions about their care and will be invaluable for the planning of future clinical trials. RaDaR is a fantastic resource that has provided and will continue to offer vital insights into rare kidney diseases, and we are proud to support it.”

    RaDaR, originally funded by the Medical Research Council, Kidney Research UK, Kidney Care UK and the Polycystic Kidney Disease Charity, is now managed and funded by the UK Kidney Association.

    Source:

    University College London

    Journal reference:

    Wong, K., et al. (2024). Effects of rare kidney diseases on kidney failure: a longitudinal analysis of the UK National Registry of Rare Kidney Diseases (RaDaR) cohort. The Lancet. doi.org/10.1016/s0140-6736(23)02843-x.

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  • New Medicare payment model challenges dialysis facilities serving patients with high social risk

    New Medicare payment model challenges dialysis facilities serving patients with high social risk

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    A new study of more than 2,000 dialysis facilities randomized to a new Medicare payment model aimed to improve outcomes for patients with end-stage kidney disease has found that facilities that disproportionately serve populations with high social risk have lower use of home dialysis and transplant waitlisting and fewer kidney transplants. These facilities thus received reduced performance scores and reimbursement from Medicare.

    A high proportion of non-Hispanic Blacks and of those initiating dialysis while uninsured or Medicaid-covered also was found to be an indicator of lower use of home dialysis and transplant waitlisting and fewer kidney transplants.

    The goal of the study authors was to identify how this new payment model would help or hurt dialysis facilities treating patients with high social risk. Their analysis raises concerns that sites treating these vulnerable patients may fare poorly under the new payment model and ultimately might not have sufficient funding to remain open and care for patients.

    The rate of home dialysis in the U.S. is significantly lower than that of other developed nations. A kidney transplant is considered the best option for most patients with end- stage kidney disease.

    The new study explored the first year (2021) of the End-Stage Renal Disease Treatment Choices Model, which was developed to encourage greater use of home dialysis and kidney transplants for Medicare beneficiaries. Individuals of any age with this condition are typically eligible for Medicare coverage.

    We found that, unfortunately, the dialysis facilities that treated patients with higher social risk, including those facilities that serve higher proportions of patients who were non-Hispanic Black or Hispanic and those who were dually eligible for Medicaid and Medicare as well as those living in a highly disadvantaged neighborhood, were more likely to be financially penalized under this model.”


    Rachel Patzer, PhD, MPH, study co-author, president and CEO of Regenstrief Institute and Leonard Betley Professor of Surgery at Indiana University School of Medicine

    It is likely that the below average outcomes were a result of the socioeconomic issues faced by these patients, factors that are beyond the control of the facilities that serve them. Recognizing this, CMS had added a risk-stratification component to the payment model for subsequent years. However, analysis presented in the paper suggests that this program modification will not be sufficient to address the problem.

    “In the first year, this payment scheme inordinately penalized facilities that serve higher proportions of patients with high social risk,” said study first author Kalli Koukounas, MPH, a graduate student at Brown University School of Public Health. “As we’ve seen other pay-for-performance programs do in the past, this model, in its first year, imposed penalties at a greater rate on facilities that serve high-risk populations.”

    “This is an important finding because dialysis facilities are typically considered the medical home for patients, and facilities that disproportionately serve patients with higher social risk factors may need additional resources and care to support patients,” noted Dr. Patzer. “Much of our prior work has identified stark racial and socioeconomic inequities in access to optimal kidney failure care across the United States. We want to ensure that these facilities have more, not fewer, resources to take care of those patients.”

    Kidney failure disproportionately impacts socially disadvantaged communities due to upstream social determinants of health over decades. Major causes of kidney disease and end stage kidney failure include diabetes, obesity and hypertension.

    Research conducted by this multi-institutional study team was funded by the National Institutes of Health’s National Institute on Minority Health and Health Disparities (PIs: Amal Trivedi, M.D., MPH, and Rachel Patzer, PhD, MPH). Dr. Trivedi, of Brown University, is the senior author of the study. Kelsey Drewry, PhD, M.A., of Regenstrief and Indiana University School of Medicine, is a co-author.

    The study authors conclude that their “findings, coupled with the escalation of penalties to as much as 10 percent in future years, support monitoring the ETC [End-Stage Renal Disease Treatment Choices] model’s continued impact on dialysis facilities that disproportionately serve patients with social risk factors, as well as its influence on outcomes and disparities in care among patients treated in these sites.”

    Source:

    Journal reference:

    Koukounas, K. G., et al. (2024). Social Risk and Dialysis Facility Performance in the First Year of the ESRD Treatment Choices Model. JAMA. doi.org/10.1001/jama.2023.23649.

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