Kidney-Failure Risk Projection for the Living Kidney-Donor Candidate.

[Clark]

http://www.ncbi.nlm.nih.gov/pubmed/26544982

Kidney-Failure Risk Projection for the Living Kidney-Donor Candidate.
N Engl J Med. 2015 Nov 6. [Epub ahead of print]
Grams ME, Sang Y, Levey AS, Matsus***a K, Ballew S, Chang AR, Chow EK, Kasiske BL, Kovesdy CP, Nadkarni GN, Shalev V, Segev DL, Coresh J, Lentine KL, Garg AX; Chronic Kidney Disease Prognosis Consortium.


Abstract
Background
Evaluation of candidates to serve as living kidney donors relies on screening for individual risk factors for end-stage renal disease (ESRD). To support an empirical approach to donor selection, we developed a tool that simultaneously incorporates multiple health characteristics to estimate a person's probable long-term risk of ESRD if that person does not donate a kidney.

Methods
We used risk associations from a meta-analysis of seven general population cohorts, calibrated to the population-level incidence of ESRD and mortality in the United States, to project the estimated long-term incidence of ESRD among persons who do not donate a kidney, according to 10 demographic and health characteristics. We then compared 15-year projections with the observed risk among 52,998 living kidney donors in the United States.

Results
A total of 4,933,314 participants from seven cohorts were followed for a median of 4 to 16 years. For a 40-year-old person with health characteristics that were similar to those of age-matched kidney donors, the 15-year projections of the risk of ESRD in the absence of donation varied according to race and sex; the risk was 0.24% among black men, 0.15% among black women, 0.06% among white men, and 0.04% among white women. Risk projections were higher in the presence of a lower estimated glomerular filtration rate, higher albuminuria, hypertension, current or former smoking, diabetes, and obesity. In the model-based lifetime projections, the risk of ESRD was highest among persons in the youngest age group, particularly among young blacks. The 15-year observed risks after donation among kidney donors in the United States were 3.5 to 5.3 times as high as the projected risks in the absence of donation.

Conclusions
Multiple demographic and health characteristics may be used together to estimate the projected long-term risk of ESRD among living kidney-donor candidates and to inform acceptance criteria for kidney donors. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases and others.).

PMID: 26544982

[Clark]

http://livingdonorsarepeopletoo.com/kidney-donors-risk-of-end-stage-renal-disease-again/

Kidney Donors’ Risk of End-stage Renal Disease – AGAIN

Recently, a media blitz heralded the arrival of an end-stage renal disease prediction calculator for potential living kidney donors, backed up by a prestigious publication in the New England Journal of Medicine. I glanced at the study, noticed that it used the “woefully incomplete” and “useless” OPTN database, and it only pulled living kidney donors from 2005 onward. Which is not good.

You see, OPTN has been collecting (inefficiently) identifying information (aka social security number) on living donors since 1993. The Secretary of Health mandated one year of follow-up on all living donors in 2000. In addition, prior studies indicate that living kidney donors who progress to kidney failure will do so 17-20 years post-donation. These facts led me to believe that the researchers were more interested in minimizing the risk of ESRD for LKDs rather than warning us of our true probability.
And since I have written about this very topic many, MANY times in the past 7 years, I have no inclination to rehash myself. Fortunately, Steiner did much of the work for me in his editorial commentary on the published paper.
…

[Clark]

http://www.nejm.org/doi/full/10.1056/NEJMe1513891

EDITORIAL
The Risks of Living Kidney Donation
Robert W. Steiner, M.D.
New England Journal of Medicine
DOI: 10.1056/NEJMe1513891

Only candidates with an apparent low risk of kidney disease are accepted as living kidney donors. Postdonation studies that extend up to 12 years have shown rates of end-stage renal disease (ESRD) among donors that are similar to those observed in the general population, which suggests minimal risk from the inevitable reduction in the glomerular filtration rate (GFR) that occurs at donor nephrectomy.1 However, a recent 7.6-year study in the United States showed that the incidence of ESRD was 8 times as high among donors as among well-selected nondonor controls.2 A similar 15.2-year study in Norway showed that the risk was 11 times as high.3 The magnitude of these relative risks has been debated, but when predonation risks of ESRD are multiplied by the relative risk of donation, significantly greater absolute postdonation risks are predicted. However, the absolute rates of ESRD were low in both studies, which reinforced the prevailing “low risk” characterization of donation.

….

Nonetheless, the present study by Grams et al. is a noteworthy attempt to address quantitatively the growing perception that donor candidates have markedly varied risks of ESRD, and some candidates who are currently considered to be at unacceptably high risk may have lower risks than others who are currently deemed to be at acceptable risk. Past efforts to address this pressing problem have lacked the precision that we all desire.4 The present study initiates an approach that may improve the defensible selection and counseling of the admirable persons who are considering kidney donation.