Journal Article Annotations
2018, 4th Quarter
Transplant Psychiatry
Annotations by Paula Zimbrean, MD, FACLP
January 2019
- Kidney transplant outcomes in recipients with cognitive impairment: a National Registry and prospective cohort study
- Psychosocial health and lifestyle behaviors in young adults receiving renal replacement therapy compared to the general population: findings from the SPEAK study
PUBLICATION #1 — Transplant Psychiatry
Kidney transplant outcomes in recipients with cognitive impairment: a National Registry and prospective cohort study
Thomas AG, Ruck JM, Shaffer AA, et al
Abstract: Transplantation 2018 Aug 27 (Epub ahead of print)
Background: Cognitive impairment is common in patients with end-stage renal disease and is associated with poor outcomes on dialysis. We hypothesized that cognitive impairment might be associated with an increased risk of all-cause graft loss (ACGL) in kidney transplant (KT) recipients.
Methods: Using the Modified Mini-Mental State (3MS) examination, we measured global cognitive function at KT hospital admission in a prospective, two-center cohort of 864 KT candidates (8/2009-7/2016). We estimated the association between pre-KT cognitive impairment and ACGL using Cox regression, adjusting for recipient, donor, and transplant factors.
Results: In living donor KT (LDKT) recipients, the prevalence was 3.3% for mild impairment (60≤3MS<80) and 3.3% for severe impairment (3MS<60). In deceased donor KT (DDKT) recipients, the prevalence was 9.8% for mild impairment and 2.6% for severe impairment. LDKT recipients with cognitive impairment had substantially higher ACGL risk than unimpaired recipients (5-year ACGL: 45.5% vs 10.6%, p<0.01; aHR any impairment: 5.40 (95% CI: 1.78-16.34), p<0.01; aHR severe impairment: 5.57 (95% CI: 1.29-24.00), p=0.02). Similarly, DDKT recipients with severe impairment had higher ACGL risk than recipients without severe impairment (5-year ACGL: 53.0% vs 24.2%, p=0.04; aHR severe impairment: 2.92 (95% CI: 1.13-7.50), p=0.03).
Conclusions: Given the elevated risk of ACGL among KT recipients with cognitive impairment observed in this two-center cohort, research efforts should explore the mechanisms of graft loss and mortality associated with cognitive impairment and identify potential interventions to improve posttransplant survival.
On PubMed: Transplantation 2018 Aug 27 (Epub ahead of print)
Annotation
Type of study: Prospective cohort study
The finding: Patients with pretransplantation cognitive impairment had a higher risk for graft loss after kidney transplantation.
Strength and weaknesses: This is a prospective study of 824 kidney transplant recipients who all underwent cognitive screening upon admission for kidney transplantations and were followed for a median of 3.3 years. The study took place at two transplant centers. The authors report the risk for graft loss for patients with cognitive impairment. The analysis took into consideration multiple possible confounding variables including demographic information (age, education, employment status, insurance status), recipient medical status (years on dialysis, diabetes status, panel reactive antibody [PRA] at transplant, Hepatitis C Virus [HCV] infection, body mass index [BMI], hypertension status, history of transplantation, Charlson Comorbidity Index [CCI]), donor characteristics (age, BMI), and transplant characteristics (recipient and donor both male, zero HLA mismatches, blood type incompatibility, and transplant date). For deceased donor kidney transplant (DDKT) recipients, the analysis was adjusted for recipient factors (sex, Black race, Hispanic ethnicity, years on dialysis, diabetes status, PRA at transplant, college education, BMI, hypertension status, history of transplantation, and CCI), donor factors (kidney donor profile index [KDPI]) , and transplant factors (CIT and transplant date).
The limitations of this study consist in lack of data about the significance of cognitive impairment in patients with ESKD and the fact that social support as a risk factor for graft loss was not included in the analysis.
Relevance: Cognitive impairment is common in patients with end stage kidney disease and continues to be found after kidney transplantation. Since it is a common finding in this population, it tends to be overlooked as a risk factor for poor outcomes posttransplantation. Transplant clinicians may consider routine cognitive screening as a component of the pretransplant evaluation in order to allow implementation of supportive interventions that can reduce the risk for graft loss.
PUBLICATION #2 — Transplant Psychiatry
Psychosocial health and lifestyle behaviors in young adults receiving renal replacement therapy compared to the general population: findings from the SPEAK study
Hamilton AJ, Caskey FJ, Casula A, Ben-Shlomo Y, Inward CD
Abstract: Am J Kidney Dis 2019; 73(2):194-205
Rationale & Objective: Patients in late adolescence and early adulthood receiving renal replacement therapy (RRT) face disruption to normal activities, which affects well-being. We aimed to define psychosocial and lifestyle outcomes for young adults on RRT compared to the general population.
Study Design: We undertook a cross-sectional survey (the SPEAK [Surveying Patients Experiencing Young Adult Kidney Failure] Study) using validated measures and general population comparator data from the Health Survey for England and Avon Longitudinal Study of Parents and Children. Additional clinical information was obtained from the UK Renal Registry.
Setting & Participants: 16- to 30-year-olds receiving RRT.
Outcomes: Psychosocial health and lifestyle behaviors.
Analytical Approach: We compared outcomes between populations using age- and sex-adjusted regression models, weighted to account for response bias by sex, ethnicity, and socioeconomic status. Our findings were used to update recent meta-analyses.
Results: We recruited 976 young adults and 64% responded to the survey: 417 (71%) with kidney transplants and 173 (29%) on dialysis therapy. Compared to the general population, young adults on RRT were less likely to be in a relationship and have children and more likely to live in the family home, receive no income, and be unable to work due to health. They had poorer quality of life, worse well-being, and twice the likelihood of a psychological disturbance (OR, 2.7; 95% CI, 2.0-3.7; P<0.001). They reported less smoking, alcohol and drug abuse, and crime. In a meta-analysis, our study showed the greatest differences in quality of life compared to the general population.
Limitations: Cross-sectional study design, meaning that we could not track the impact of treatment changes on the outcomes.
Conclusions: This study involving a large cohort of young adult transplant recipients and dialysis patients provides evidence of worse psychosocial outcomes but more positive lifestyle behaviors in young adults on RRT compared to the age-matched general population.
On PubMed: Am J Kidney Dis 2019; 73(2):194-205
Annotation
Type of study: Case control study
The finding: Young adults with RRT are less likely to be married, have children and more likely to live at home compared to general populations. They are also shorter. They were twice as likely to have psychological problems, but less likely to smoke or misuse substances. They are more likely to be unemployed despite having similar education levels compared to general population.
Strength and weaknesses: SPEAK (Surveying Patients Experiencing Young Adult Kidney Failure) Study is a single cross-sectional online self-completion survey for 16- to 30-year-olds receiving RRT in United Kingdom renal units. 976 young adults were surveyed for health related behaviors, with a response rate of 64%. The authors are reporting differences between responders and non responders, and the analysis compared findings in the dialysis group, transplantation groups and general population. The limitations of the study originate in the cross sectional design, self-reporting measures and lack of control for selection bias.
Relevance: Young adults are a particular age group that worry transplant psychiatrists due to high rate of poor adherence and adjustment difficulties. Although this study reports on young adults with RRT, not just transplantation, the findings are highly relevant to transplant psychaitrists since 80% of the group had received a kidney transplant and young adults on RRT are often evaluated for transplant candidacy.
