Improving access of the patients to renal trasplantation - Lluis Pallardo.pdf · Medical ad...
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Improving the access of the patients to renal trasplantation
Luis M. Pallardó MD, PhD Hospital Universitario Dr Peset
University of Valencia Valencia, Spain
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Incident ESRD rates per million population by country, unadjusted. EDTA Report 2014
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RRT Incidence rates (pmp) by country in 2013 Data from USRDS in 2013
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Stability in the RRT incidence in some countries Data from USRDS in 2013
Canada Denmark Sweden Scotland Finland
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RRT incidence rates between 1980 and 2013. The 18th Annual Report UK Renal Registry
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The RRT incidence in Spain 2007-13 The Spanish Renal Registry 2013
Martín-Escobar E et al. Nefrologia 2016;36:97-120
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Increasing the RRT incidence in some countries Data from USRDS in 2013
México Singapore USA Rpb Korea, Malasia Thailand Chile Croatia Phylippinas Russia Bangladesh
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Incident percentages ERA-EDTA Report 2014
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Incident percentages ERA-EDTA Report 2014
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Prevalence rates of ESRD pmp by country, unadjusted. ERA-EDTA Report 2014
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Prevalent percentages ERA-EDTA Report 2014
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Modality changes in prevalent RRT patients, 1999–2014. 18th Annual Report UK Renal Registry
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Age profile of prevalent RRT patients by modality on 2014
18th Annual Report UK Renal Registry
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Modality changes in prevalent RRT patients, 2007-13 The Spanish Renal Registry 2013
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Prevalent percentages ERA-EDTA Report 2014
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Prevalent percentages ERA-EDTA Report 2014
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Trends in the number of ESRD prevalent cases (in thousands) by modality, in the U.S. population, 1996-2013
2015 Annual Data Report, USRDS
17
30%
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Why to do more renal transplants?
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Why to do more renal transplants?
• Increase of patient survival – Wolfe RA et al. N Engl J Med 1999;341:1725-1730.
– Macrae J, et al. Int Urol Nephrol 2005; 37: 641.
– Lloveras J, et al. Transplanation 2015; 99: 991–996.
• Increase of quality of life – Laupacis A, et al. Kidney Int 1996; 50:235–242. – Tonelli M, et al. Amer J Transplant 2011; 11: 2093-2109.
– Dukes JL, et al. Clin Transplant 2013.
• Is more cost-effective than dialysis – Whiting JF, et al. Transplant Proc. 1999;31:1320–1321. – Arrieta J, et al. Nefrologia 2011;31:505-13.
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Adjusted survival (after the day 91) in incident dialysis
patients and patients receiving a first transplant (between 2005 and 2009).ERA-EDTA Report 2014
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Wolfe RA, et al. N Engl J Med 1999;341:1725-1730.
Adjusted Relative Risk of Death among 23,275 Recipients of a First Cadaveric Transplant
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Wolfe RA, et al. N Engl J Med 1999;341:1725-1730.
Outcome among Recipients of First Cadaveric Transplants, According to Characteristics at the Time of Initial Placement on the Waiting List, 1991–1997.
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ERA-EDTA Report 2014
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Main determinants of renal Tx
• Organ shortage
• Medical and non-medical conditions
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Deceased Donor Age in Spain 1992-2015 ONT Annual Report 2015
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NHBD Renal Tx in Spain 1995-2014 ONT Annual Report 2014
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Living donor renal Tx Activity ONT Annual Report 2014
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Renal Transplantation in Spain 1993-2014 ONT Annual Report 2014
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???Waiting list for renal transplatation ONT Annual Report 2014
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Medical ad nonmedical conditions The way to ESRD
CRD ESRD RRT (TX/ PD-HD)
• Comprehensive nephrological care
• Educational and Sociological circumstancies of the patients, including understanding of the disease and their different treatments
• Programmed vs non-programmed initiation of RRT
• For profit vs non for profit dialysis Units
• Local or regional facilities for Tx
• Comorbidities
• Age
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Medical ad nonmedical conditions The way to ESRD
CRD ESRD RRT (PD-HD / TX)
• Nephrological care
• Programmed vs non-programmed initiation of RRT
• For profit vs non for profit dialysis Units
• Local or regional facilities for Tx
• Educational and sociological circumstancies of the patients, including comprehension of the disease
• Comorbidities
• Age
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……
• Patients older than 65 are the ones that more intensively increase
in the RRT population
• This group is underepresented in the transplanted population
• Age ‘per se’ cannot be a restrictive criteria to access to renal
transplantation, and there should be no upper limit for excluding
patients
• Older patients must be evaluated as the standard ESRD patients to
be included in the waiting list for renal transplantation, with
particular attention to the cardiovascular and malignancy riscs, and
a proper management after transplantation
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‘Old for old’ renal transplantation Influence of age-matching on actual graft survival (using a cut-off age of 55 years).
Wolfgang Arns et al. Nephrol. Dial. Transplant. 2007;22:336-341
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‘Old for old’ renal Tx The Eurotransplant Senior Programme
Frei et al. American Journal Transplantation 2005; 5:50-57
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Patient survival in recipients of kidneys from donors >65 years old versus patients remaining on dialysis in a paired analysis
Catalan Renal Registry 1990-2010
Lloveras J, et al. Transplanation 2015; 99: 991–996
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Survival Benefit From Kidney Transplantation Using Kidneys From Deceased Donors Aged ≥75 Years: A Time‐Dependent Analysis
Catalan Renal Registry 1990-2010
Pérez MJ et al. American Journal of Transplantation 2016; 16:2724-2733.
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Mortality (HR) according to transplant status and CCI
Sørensen VR et al. Transplantation 2015. doi: 10.1097/TP.0000000000001002
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KM patient survival of WL vs Tx patients >70 years of age
Period 1990-99 Period 2000-05
Heldal K, etal. Nephrol Dial Transplant (2010) 25: 1680–1687
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Patient survival depending on the transplant era
Heldal K, etal. Nephrol Dial Transplant (2010) 25: 1680–1687
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Death censored graft survival (A)
and Patient Survival in octagenarians (B)
(A) (B)
Lønning K, etal. Transplantation DOI: 10.1097/TP.0000000000001363
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In conclusion:
• Conditioning circumstancies to renal Tx can vary
between different regions and countries.
• Medical and nonmedical factors can determine access
to renal Tx, and they must be evaluated in order to
find the proper solution.
• Aged population with ESRD is increasingly prevalent,
and their expectation to be transplanted depends on
taking advantage of older deceased, as well as, living
donors.
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Thanks!!