Rehospitalization after kidney transplant caused by complexity of the condition, not poor quality of care

Most early rehospitalization after kidney transplant caused by complexity of the condition, not poor quality of care

A study of over 750 kidney transplant patients over a five-year period conducted by researchers at the Perelman School of Medicine at the University of Pennsylvania has found that 90% of early rehospitalizations (within 30 days of surgery) were caused by complex medical factors related to the transplantation process. Only nine percent of rehospitalizations – which occurred among only three percent of the entire group of patients – were categorised as potentially preventable.

The study, published online this week in the American Journal of Transplantation, found that 237 patients (nearly one-third) were rehospitalized early following surgery, with a median of nine days to rehospitalization after discharge from kidney transplant. In most of these cases, the readmissions were unplanned and occurred as a result of common postsurgical complications. Deep vein thrombosis (blood clots), post-operative pain, organ rejection, fluid imbalances including volume overload (too much fluid in the blood) or volume depletion (decrease in volume of blood plasma, potentially leading to shock), and wound infections were key complicating factors leading to early rehospitalisation.

“Nationally, high rates of early rehospitalization after kidney transplantation have been reported, but little information is available about what caused these events and whether they could be prevented,” said lead study author Meera Nair Harhay, MD, MSCE, instructor of Medicine in the Renal, Electrolyte and Hypertension Division at Penn. “Early rehospitalization has also been examined by Medicare as a hospital quality of care indicator, with financial penalties for early rehospitalization after certain medical conditions. However, our findings indicate that transplant recipients are a particularly vulnerable group that often requires additional care after undergoing surgery and being exposed to new medications.”

In the study, which is the first to use intensive chart review to assess preventability of early rehospitalization, two physicians independently examined the medical charts of the 237 readmitted transplant patients. Only 19 cases were found to be preventable readmissions by the reviewing physicians. Preventable causes of readmission identified by the study include 1) patients not having had an outpatient physician/nurse practitioner assessment before being admitted, 2) an alternative medical regimen not having been prescribed at discharge, 3) patients not having been compliant with their medication regimen, and 4) inadequate outpatient diagnostic or therapeutic procedures having been available.

The study also found that 30% of rehospitalized patients were originally discharged after their transplant on the weekend, versus 23% of patients who were not readmitted –a statistically significant finding highlighting the need for careful transitions of care when staffing is variable and more limited, such as occurs on the weekends. “If further multicenter studies confirm these findings, transplant centers should consider augmenting staffing and the oversight related to weekend discharges,” said senior author Peter Reese MD, MSCE, assistant professor of Medicine and Epidemiology at Penn.

The study also revealed how long waiting times for transplantation increase the risk of post-transplant complications. For every year of additional waiting time prior to kidney transplantation, recipients were 10% more likely to experience early rehospitalization. Kidney transplant recipients who were rehospitalized within 30 days of transplant were 55% more likely to die within a six-year follow-up period than those who were not rehospitalized. “These findings indicate that early rehospitalization may be a strong signal of patient vulnerability, and such patients may benefit from more careful clinical monitoring post-transplant,” said Harhay.

virtualmedicalcentre.com

(Source: University of Pennsylvania, American Journal of Transplantation) 

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'Give the Gift of Life Walk' Sept 11th in Tillsonburg, Ontario, Canada

Walking for a great cause

By Kristine MacDougall, Tillsonburg News

You can make a difference.

That's the message behind The Kidney Foundation of Canada's annual Give the Gift of Life Walk September 11, at Tillsonburg District Memorial Hospital.

"This is the first time it's ever been held in Tillsonburg," said Greg D'Hulster, organizer for the walk. "I've volunteered for The Kidney Foundation of Canada before, and in other areas of the province, it seemed to be a success," he said.

D'Hulster has been directly affected by kidney failure and understands the importance of events such as the Give the Gift of Life Walk.

"We have a son that was born with kidney problems," he said of his 15-year-old son Dylan. "Back in 2001, when he was six I gave him one of my kidneys."

Since then, Dylan had been living a healthy, normal life, but that all changed last year, when he was put back on dialysis in March 2010.

"The kidney that I gave him quit working and he's back on dialysis right now," D'Hulster said. "Usually a transplanted kidney will last longer than eight or nine years, but because it's a foreign object in his body it can quit working at any time, for really no reason at all."

Cance, as well as heart and stroke disease may be better known across Canada, and may affect more people, however, the number of people affected by kidney disease or kidney failure has steadily increased over the past 20 years. D'Hulster said events like the Give the Gift of Life Walk are an important way for people to learn about kidney disease, its impact on communities and families, as well as the importance of organ donation.

"I don't think people realize that just one person donating an organ can save up to eight people. It's pretty dramatic - one person signing their donor card," he said. "(Organ donation helps) get one of those people out of there, and off of dialysis. It makes a huge difference in their lives."

Dylan is currently on a waiting list for another kidney transplant and undergoes dialysis treatment in Tillsonburg 18 hours a week - three days a week, at six hours a day.

The money raised Sunday will stay locally and go towards the dialysis unit at the Tillsonburg District Memorial Hospital.

Approximately 45 walkers have registered so far, and are expected to participate in the five kilometer walk. To register for the event or for more information, you can visit www.kidney.ca/ontario walk or call 1-800-387-4474.

The Give the Gift of Life Walk takes place Sunday September 11, 2011 at the Tillsonburg District Memorial Hospital, and begins at 10:30 am.

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Nephrologists Discover Cause of Common Kidney Disease

Source: healthcanal.com

Nephrologists at the Miller School have solved a decades-long search for the cause of a significant form of chronic kidney disease – focal segmental glomerulosclerosis (FSGS).

Working with mouse models and a bank of patient samples, scientists have discovered the first circulating factor known to start the process leading to FSGS. The finding, a fundamental principle of the origin of kidney disease, is published in the July 31 edition of the journal Nature Medicine.

Jochen Reiser, M.D., Ph.D., professor and vice chair for research in the Department of Medicine and chief of the Division of Nephrology and Hypertension, and Changli Wei, M.D., Ph.D., assistant professor of medicine in the Division of Nephrology and Hypertension, led a team of international researchers and physicians in discovering that a soluble form of the urokinase plasminogen activator receptor (suPAR) is a factor in triggering glomerular kidney disease.

“This is truly monumental and a great team effort that paid off,” Reiser said, “because we can measure the amount of suPAR, and develop targeted treatments for that factor or prevent what it does to the kidney.”

Each kidney is made up of approximately one million glomeruli, specialized capillary beds that filter the blood. The glomeruli are composed of endothelial cells, a membrane and podocytes. The podocytes have cellular foot processes that are bridged by a slit diaphragm and that wrap around the glomerular blood vessels. Podocytes work as goalkeepers in the kidney, preventing protein from leaking into the urine. FSGS occurs due to a breakdown of podocytes, fusing them together, and allowing protein to infiltrate the urine leading to scarring of the kidney.

Focal segmental glomerulosclerosis is a common type of chronic kidney disease, with more than 5,000 new cases diagnosed each year. It often leads to end-stage renal disease, which affects approximately 20,000 people in the U.S. While podocyte gene defects are one cause, most cases have no known cause. FSGS shares similarities with diabetic nephropathy, which is often termed secondary FSGS and is the most common reason for end-stage renal disease. Reiser’s finding now explains possibly two-thirds of FSGS.

“This discovery is going to change the future of treating chronic kidney disease,” said Pascal J. Goldschmidt, M.D., Senior Vice President for Medical Affairs and Dean of the Miller School, and CEOof UHealth-University of Miami Health System. “By identifying the first circulating factor that triggers the switch for glomerular disease, Jochen and his team have ended a 40-year search by pinpointing how the kidney filtration system breaks down. Scientists around the world can now focus on developing targeted therapies to minimize that factor.”

In 2008, Reiser and Wei published another study in Nature Medicine demonstrating that urokinase receptor (uPAR) can be produced in the podocyte, activating the β3-integrin switch, a protein involved in cell signaling. Left in an active state, this switch begins to set the podocyte foot processes in motion, leading to the degradation of the filter barrier (proteinuria), eventually turning the glomeruli into scar tissue, leading to glomerular disease.

Clinical reports from nearly 40 years ago revealed that FSGS can recur within minutes of kidneytransplantation, leading physicians to theorize that there were factors in the blood that were degrading the kidney. The hunt for the FSGS factor was on, in an effort to discover one of nephrology’s biggest secrets and to help high-risk patients including children, whose recurrence ofFSGS after transplantation can be as high as 86 percent.

“There is a clear need to discern what’s causing this disease to recur so quickly in so many patients,” Wei said. “Finding the factor will not only improve post-transplant FSGS but will also teach us the reason for pre-transplant FSGS as current therapies are limited, unspecific and minimally effective.”

Over the past decade, Reiser discovered that podocytes were motile cells, and thus the filter barrier in the kidney was a dynamic rather than a static structure. Following this hypothesis, he began looking for activators of podocyte motility. He and his colleagues used genetic and molecular tools to discover, in a series of high impact publications including this paper’s finding, that blood suPAR or podocyte uPAR are what’s activating the β3-integrin switch in the podocyte. Too much suPAR in the blood and the switch remains active, degrading the podocyte and the kidney filter.

The findings were validated in kidney transplant patient samples. Reiser, director of the Peggy and Harold Katz Family Drug Discovery Center, points out the benefit of this discovery to patients: “This could potentially explain fundamental pathologic issues that occur in chronic kidney diseases.” Those with native kidney disease can now be tested for suPAR levels and provided therapies that will aim to reduce that level. Similarly, transplant patients would have elevated suPAR levels reduced before surgery, ensuring a lower risk for recurrent disease. Reiser says identifying suPAR and the β3-integrin switch opens the door to general principles for other glomerular diseases such asdiabetic nephropathy.

Wei is hopeful their five-year-long study will lead to new treatments. “Patients with FSGS and other glomerular diseases will benefit from our finding very
soon.”

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Your generosity can save or enhance the lives of up to fifty people with heart, kidneys, liver, lungs, pancreas and small intestine transplants (see allotransplantation). One tissue donor can help by donating skin, corneas, bone, tendon, ligaments and heart valves

Has your life been saved by an organ transplant? "Pay it forward" and help spread the word about the need for organ donation - In the U.S. another person is added to the national transplant waiting list every 11 minutes and 18 people die each day waiting for an organ or tissue transplant. Organs can save lives, corneas renew vision, and tissue may help to restore someone's ability to walk, run or move freely without pain. Life Begins with You

Screenings for kidney disease save Alaskan lives

Although this article is about Alaska the overview and screening tips for kidney disease are applicable everywhere and something we should all be aware of. As of April 8, 2011, of the 120,046 people waiting for an organ transplant in the United States, 94,116 are waiting for a kidney transplant.

The National Kidney Foundation notes that those with CKD are 16 to 40 times more likely to die of cardiovascular disease before developing kidney failure.

By Robin Bassett The Bristol Bay Times

Chronic kidney disease (CKD) is known as a silent killer; it's painless and progresses slowly into kidney failure. But kidney disease's impact on Americans and Alaskans is far from quiet as the CKD count quickly reaches epidemic proportions.

More than 26 million adult Americans have CKD and millions more are at risk for CKD but completely unaware of it. According to United States Renal Data System, more than 600 Alaskans have CKD. The National Kidney Foundation notes that those with CKD are 16 to 40 times more likely to die of cardiovascular disease before developing kidney failure.

Kidney failure can be treated with replacement therapy called dialysis. Another option is kidney transplant; more than 87,000 Americans are waiting for a kidney organ to become available. Living in Alaska is particularly difficult for those with CKD and kidney failure because the state has only six nephrologists (physicians trained as internists with additional training in kidney disease). All are located in Anchorage, and even though many make monthly visits to Fairbanks, Juneau and Kenai, the wait to see a nephrologist is often longer than three months.

That's why kidney screenings are critical to helping Alaskans avoid CKD.

Alaskans can receive free kidney screenings thanks to the National Kidney Foundation, which sponsors the Kidney Early Evaluation Program (KEEP). These screenings are conducted around Alaska several times annually; the last screenings evaluated more than 200 Alaskans.

At KEEP screenings, blood and urine tests, as well as blood pressure readings, are measured, and each participant meets with a clinician to discuss preliminary results. Further results are mailed to participants' homes and to their primary care providers for further work-up and referrals.

The importance of healthy, hardworking kidneys can't be overstated. Kidneys filter approximately 200 liters of blood each day, removing two liters of toxins, wastes and water. Kidneys also: regulate the body's water balance and blood pressure; support healthy bone and tissues by producing the active form of vitamin D; release a hormone that signals the bone marrow to manufacture red blood cells; keep the blood's acid levels regulated; keep minerals in balance; and retrieve necessary nutrients so that the body can reabsorb them.

Kidneys are often victims of other disease processes within the body. Diabetes is the No. 1 cause of kidney failure, with hypertension second. Kidney function screenings should be an annual event for anyone with diabetes, hypertension or with immediate family members with these conditions or histories of kidney disease or dialysis.

The Alaska Department of Health and Social Services reports that 66 percent of adult Alaskans are overweight or obese. Being overweight or obese increases the risk for diabetes, hypertension and the development of CKD.

CKD's silent and progressive nature can suddenly strike people who aren't screened: they can suffer side effects of kidney disease or even face the decision of dialysis or replacing failed kidneys with little time for prevention or preparation.

March was National Kidney Month. Use the recent landmark as motivation to increase your kidney awareness and care. The National Kidney Foundation is an important resource for help. It's dedicated to preventing kidney and urinary tract disease, improving the health and well-being of individuals and families affected by these diseases, and increasing the availability of all organs for transplantation. Visit its website at www.kidney.org.

FREE KIDNEY SCREENINGS IN ALASKA
Dates for upcoming free KEEP screenings:

• 9 a.m.-1 p.m. Saturday, May 14 at Shiloh Baptist Church, Anchorage
• 9 a.m.-1 p.m. Saturday, Oct. 1, at JP Jones Development Center, Fairbanks
• Learn more about free kidney screenings around Alaska by contacting Kristie Lemmon at 877-889-6318 or email kristie.lemmon@kidney.org.

TIPS FOR KEEPING YOUR KIDNEYS HEALTHY

• Get screened annually to find out if you already have chronic kidney disease.
• Protect your kidneys by keeping blood sugars controlled, keeping your blood pressure below 130/80, and keeping your cholesterol down.
• Manage your weight and weight loss. Studies show that overweight or obese people are at higher risk for diabetes, hypertension, and hypercholesterolemia. Obesity is also associated with a specific type of kidney disease called focal glomerulosclerosis (scarring in specific areas of the kidneys that lead to kidney failure).
• Pay attention to kidney disease warning signs: feeling tired and fatigued; difficulty concentrating; difficulty eating or sleeping; muscle cramps, especially at night; swelling in feet ankles or face, especially around the eyes; itchy and dry skin; and urge to urinate more frequently, especially at night.
• For more information on kidney awareness, visit the National Kidney Foundation website at www.kidney.org.

Robin Bassett ANP is a CDR in the USPHS detailed to Alaska Native Medical Center Internal Medicine providing nephrology services. She can be reached at 907-729-1550 or by email at rabassett@anthc.org.

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Your generosity can save or enhance the lives of up to fifty people with heart, kidneys, liver, lungs, pancreas and small intestine transplants (see allotransplantation). One tissue donor can help by donating skin, corneas, bone, tendon, ligaments and heart valves

Has your life been saved by an organ transplant? "Pay it forward" and help spread the word about the need for organ donation - In the U.S. another person is added to the national transplant waiting list every 11 minutes and 18 people die each day waiting for an organ or tissue transplant. Organs can save lives, corneas renew vision, and tissue may help to restore someone's ability to walk, run or move freely without pain. Life Begins with You