Limited access to kidney replacement therapy (KRT) in Rwanda results from financial constraints, geographic challenges, a shortage of nephrologists and equipment, as well as low public awareness. We aimed to identify the factors contributing to patients’ decisions regarding KRT and understand their perspectives on KRT, including their understanding, attitudes, and expectations. A cross-sectional mixed method design was conducted between May 2023 and March 2024, involving 180 chronic kidney disease (CKD) adult patients (> 18 years old) with an estimated GFR < 30 ml/min/1.73 m². It was conducted at outpatient nephrology clinics at King Faisal Hospital-Rwanda, Kigali University Teaching Hospital, and Rwanda Military Hospital. Quantitative data from hospital registries were analyzed in Stata SE 17.0, employing descriptive, bivariate, and multinomial techniques to determine factors associated with KRT modality choice. Additionally, 15 participants were conveniently selected for interviews and analysis of transcripted records were conducted using ATLAS.ti. The mean age was 52.2 [SD = 13.9] years, with a higher representation of males. Two-thirds of the participants had end-stage kidney disease (kidney failure) with a mean eGFR of 14.64 ml/min/1.73m2. Most participants (72.1

Introduction: Rather than generating 1 transplant by directly donating to a candidate on the waitlist, deceased donors (DDs) could achieve additional transplants by donating to a candidate in a kidney paired donation (KPD) pool, thereby, initiating a chain that ends with a living donor (LD) donating to a candidate on the waitlist. We model outcomes arising from various strategies that allow DDs to initiate KPD chains. Methods: We base simulations on actual 2016 to 2017 US DD and waitlist data and use simulated KPD pools to model DD-initiated KPD chains. We also consider methods to assess and overcome the primary criticism of this approach, namely the potential to disadvantage blood type O-waitlisted candidates. Results: Compared with shorter DD-initiated KPD chains, longer chains increase the number of KPD transplants by up to 5% and reduce the number of DDs allocated to the KPD pool by 25%. These strategies increase the overall number of blood type O transplants and make LDs available to candidates on the waitlist. Restricting allocation of blood type O DDs to require ending KPD chains with LD blood type O donations to the waitlist markedly reduces the number of KPD transplants achieved. Conclusion: Allocating fewer than 3% of DD to initiate KPD chains could increase the number of kidney transplants by up to 290 annually. Such use of DDs allows additional transplantation of highly sensitized and blood type O KPD candidates. Collectively, patients of each blood type, including blood type O, would benefit from the proposed strategies.

disease.In some cases, severe COVID-19 pneumonia is associated with kidney injury known as COVID-19-Associated Nephropathy, the exact mechanisms of which are unclear.A 25-year-old AA female presented with mild respiratory symptoms and positive for SARS-CoV-2 and was admitted to Emergency in March 2020.Her serum creatinine (sCr) was 1.4 mg/dL, albumin 2.92 g/dL; she recovered clinically and was discharged.She returned to hospital 25 days later with severe kidney failure, sCr of 28 mg/dL, potassium of 5.6 mmol/L and urine protein/creatinine (uPCR) of 10355 mg/g.She was initiated on hemodialysis.Kidney biopsy showed CG with acute tubular necrosis with direct invasion of the glomerular cells by particles resembling coronavirus.Hemodialysis was discontinued and she was discharged home on oral prednisone at 1mg/kg/day.After 5 months, she was tapered off of prednisone and her sCr improved to 2.6 mg/dL with uPCR of 3133 mg/g.Genetic testing with Renasight, a 382 renal gene panel was performed, yielding homozygosity for the APOL1 risk allele (c.[1024A>G;1152T>G] (p.[Ser342Gly;Ile384Met]) (G1 allele).High-risk APOL1 risk variants occur in 13% of AAs.These individuals have an estimated 4% lifetime risk for incurring FSGS.However, a '2 nd hit' is necessary for kidney disease to develop.COVID-19 may lead to kidney injury due to tissue ischemia, cytokine storm, hypercoagulability or direct viral-mediated mechanisms.In COVID-19 related kidney biopsies, CG is often described.Although glucocorticoid sensitivity in such patients is not well-defined, our patient showed response to oral prednisone.This case adds to growing evidence that SARS-CoV-2 infection contributes to CG.The dual effect of high-risk APOL1 variants and SARS-CoV-2 in effecting CG remains to be elucidated.Testing with a broad renal genetic panel could help define genetic variants that promote complications from SARS-CoV-2 infection.

Over the past 65 years, kidney transplantation has evolved into the optimal treatment for patients with kidney failure, dramatically reducing suffering through improved survival and quality of life. However, access to transplant is still limited by organ supply, opportunities for transplant are inequitably distributed, and lifelong transplant survival remains elusive. To address these persistent needs, the National Kidney Foundation convened an expert panel to define an agenda for future research. The key priorities identified by the panel center on the needs to develop and evaluate strategies to expand living donation, improve waitlist management and transplant readiness, maximize use of available deceased donor organs, and extend allograft longevity. Strategies targeting the critical goal of decreasing organ discard that warrant research investment include educating patients and clinicians about potential benefits of accepting nonstandard organs, use of novel organ assessment technologies and real-time decision support, and approaches to preserve and resuscitate allografts before implantation. The development of personalized strategies to reduce the burden of lifelong immunosuppression and support "one transplant for life" was also identified as a vital priority. The panel noted the specific goal of improving transplant access and graft survival for children with kidney failure. This ambitious agenda will focus research investment to promote greater equity and efficiency in access to transplantation, and help sustain long-term benefits of the gift of life for more patients in need.

Many patients experiencing anemia in CKD remain untreated until dialysis.We describe characteristics of patients with/without dialysis dependent CKD and anemia receiving a transfusion or IV iron in DISCOVER CKD.Data for patients (aged >18 y) with CKD and anemia were taken from UK CPRD, Japan JMDV and US LCED databases.Index: first Hb <12/13 g/dL (female/male) or an anemia therapy (iron, ESA or transfusion) prescription on/after: dx code for CKD (stage 3A+) or dialysis or 2nd of two eGFR measures <60 mL/min/1.73m2>90 days apart between Jan 2008 and Mar 2020.In total, 27% of 72,429 patients were treated with anemia therapies during follow-up, of which 25% was transfusion or IV iron.Patients from the US and Japan had a higher proportion of comorbidities compared to patients from the UK.Median Hb ranged 7.9-8.9for those receiving a transfusion and 8.9-10.5 for those receiving IV iron, Table 1.There were clear country differences observed in the routine clinical care of anemia in patients with CKD.Transfusion and IV iron were commonly used as rescue therapies despite their invasive nature and well-recognized associations between transfusions and adverse reactions such as allosensitization and infection.

Kidney disease is a common, complex, costly, and life-limiting condition. Most kidney disease registries or information systems have been limited to single institutions or regions. A national US Department of Veterans Affairs (VA) Renal Information System (VA-REINS) was recently developed. We describe its creation and present key initial findings related to chronic kidney disease (CKD) without kidney replacement therapy (KRT). Data from the VA's Corporate Data Warehouse were processed and linked with national Medicare data for patients with CKD receiving KRT. Operational definitions for VA user, CKD, acute kidney injury, and kidney failure were developed. Among 7 million VA users in fiscal year 2014, CKD was identified using either a strict or liberal operational definition in 1.1 million (16.4%) and 2.5 million (36.3%) veterans, respectively. Most were identified using an estimated glomerular filtration rate laboratory phenotype, some through proteinuria assessment, and very few through International Classification of Diseases, Ninth Revision coding. The VA spent ∼$18 billion for the care of patients with CKD without KRT, most of which was for CKD stage 3, with higher per-patient costs by CKD stage. VA-REINS can be leveraged for disease surveillance, population health management, and improving the quality and value of care, thereby enhancing VA's capacity as a patient-centered learning health system for US veterans.

As proof of concept, we simulate a revised kidney allocation system that includes deceased donor (DD) kidneys as chain-initiating kidneys (DD-CIK) in a kidney paired donation pool (KPDP), and estimate potential increases in number of transplants. We consider chains of length 2 in which the DD-CIK gives to a candidate in the KPDP, and that candidate's incompatible donor donates to theDD waitlist. In simulations, we vary initial pool size, arrival rates of candidate/donor pairs and (living) nondirected donors (NDDs), and delay time from entry to the KPDP until a candidate is eligible to receive a DD-CIK. Using data on candidate/donor pairs and NDDs from the Alliance for Paired Kidney Donation, and the actual DDs from the Scientific Registry of Transplant Recipients (SRTR) data, simulations extend over 2 years. With an initial pool of 400, respective candidate and NDD arrival rates of 2 per day and 3 per month, and delay times for access to DD-CIK of 6 months or less, including DD-CIKs increases the number of transplants by at least 447 over 2 years, and greatly reduces waiting times of KPDP candidates. Potential effects on waitlist candidates are discussed as are policy and ethical issues.

Introduction: “One Belt & One Road Initiative” is a development strategy adopted by the Chinese government involving countries and international organizations from all over the World for economic and commercial development. During the One Belt & One Road 1st International Workshop on Leadership & Management, Quality and Innovation in Organ Procurement was held in Kunming (China) in December 2019, 81 participants from 33 countries worked together towards the common objective of establishing essential recommendations on 4 strategic chapters leadership, management, quality and innovation in organ donation necessary to achieve self-sufficiency in their organ donation programs. The group’s objective was to identify issues related to and measures towards the self-sufficiency in organ donation programs. Methodology: Previous to the meeting, an online survey was designed and distributed via an online survey among participants of the workshop to gather the necessary information about the 4 strategic chapters. The final survey with 46 questions, included 2 delegate’s professional information questions, 25 questions on leadership and management, 9 questions in quality, 6 questions on innovation and 4 questions in donation activity and healthcare systems. Results: The survey was sent to 58 responders from 44 countries. A total of 42 responses were received from 34 countries. Respondents were: 31.16% Key Donation Persons (national 14.5%, regional 7.14% and hospital 9.52%); 21.4% members of a donation/transplantation surgical team; 16.67% member of the transplant medical team; 4.76% Ministry of Health employees. LEADERSHIP AND MANAGEMENT 38 responses have a legal framework for donation & transplantation (D&T) (92.6% of total responses). 28 responses have an Opting in system (68.29%). 32 responses reported having a have a National Donation & Transplantation (D&T) Office (76.19%) and 31 of them are funded by the Minister of Health (96.8%). In 27 responses, the KDP role is defined (65.85%). From these, 22 of them are officially appointed (81.48%), being the Hospital Director responsible in 17 of the appointments (62.96%). QUALITY 24 responses have Organ Donation process guidelines/procedures/protocols at national level (68.5%), 17 have protocols at hospital level (48.57%). 22 responses declared having an authorization or accreditation system for the donor hospitals in their country or region (62.86%). INNOVATION 25 responded affirmed NOT to use Normothermic regional perfusion in Donation after Cardiac Death (DCD) (73.53%), while 18 NOT use any ex-vivo perfusion machine (52.94%). 7 respondents did not have a Tissue Bank at national level (20.59%), and among them. Conclusion: The survey response rate was high (81%) and the respondent’s professional profile was heterogeneous. The survey results were used to elaborate in a second phase –already done - the “Recommendations for belt & road region on leadership, management, quality and innovation to achieve self-sufficiency in organ donation”.

Introduction: Kidney transplantation (KT) is the preferred replacement treatment for patients with chronic kidney disease (CKD). It provides better quality of life (QoL) besides many other benefits. World Health Organization defines QoL as an individual’s awareness of their position in life in the context of the culture and value systems in which they live and relate to their goals, hopes, standards and concerns. Several studies on QoL of patients who had KT are done using standardized qualitative and quantitative methodologies around the world. We haven’t come across publication on QoL after KT from Africa. This study was done to determine the quality of life and associated factors of kidney transplant patients in Ethiopia, Eastern Africa. Methodology: The study was conducted at Ethiopian Ministry Health’s National kidney transplant center located at Saint Paul Hospital Millennium Medical College, Addis Ababa Ethiopia. It was an institution-based cross-sectional study design. A validated questionnaire KTQ-25 was used for data collection on 97 kidney transplant patients. The study was conducted from Jan 28, 2019 to April 5, 2019. Descriptive analyses of demographic and QoL variables were conducted. Also demographic and patient characteristic variables included in and bivariate analyses were conducted using student t-test and one way analysis of variance or ANOVA were used to determine relationships between demographics, and QoL. Results and Discussion: The mean of QoL in this study was 6.06 ∓ 0.79, the maximum score was obtained in appearance dimension and the minimum score was obtained in fear dimension. In comparing the quality of life scores based on the socio-demographic factors, no statistically significant difference was observed. In comparing the quality of life scores based on health-related and functional characters a statistical difference was observed between the quality of life score based on the time after transplant (p=0.035) and the duration returning to their job after transplant (p=0.031). P-value < 0.05 is considered as statistical significance. Published studies couldn’t be found about quality of life in kidney transplant patients as many worldwide and couldn’t come across with such studies in Africa. Despite this fact QoL in Ethiopia is good measuring a mean score of 6.068 + 0.79 which is higher than that of Rebollo in Spain (5.9 ∓1.18), Oveilly study in US (4.5 ∓1.2), Iran (4.9 ∓1.27) and Chinese (4.8 ∓1.43) which has been reported with the same questionnaire. Conclusions: Even though Kidney transplantation was started only four years back, Ethiopian kidney transplant patients’ quality of life level is better. Time after transplant and the duration to return to their job after transplant has a statistically significant association with quality of life. Having a counseling session for those who score low in quality of life domains is recommended. Keywords: quality of life, kidney transplantation, associated factorsSaint Paul Hospital Millennium Medical College. Ethiopian Health Ministry. References: 1. Wyld M, Morton RL, Hayen A, Howard K, Webster AC. A systematic review and meta analysis of utility based quality of life in chronic kidney disease treatments. PLoS Med 2012;9(9):e1001307. 2. Laupacis A, Pus N, Muirhead N, Wong C, Ferguson B, Keown P. Disease specific questionnaire for patients with a renal transplant. Nephron. 1993;64(2):226–231 3. World Health Organization. (1997). Measuring Quality of Life. Retrieved 2017 May 05 from http://www.who.int/mental_health/media/68.pdf 4. Weng, L.C., Dai, Y.T., Huang, H.L., & Chiang, Y.J. (2010). Self-efficacy, self-care behaviors and quality of life of kidney transplant recipients. Journal Of Advanced Nursing. 66, (4), 828-838. 5. Kostro, J. Z., Hellmann, A., Kobiela, J., Skóra, I., Niemierko, M.L., Slizien, A.D., & Sledzinski, Z. (2016). Quality of Life After Kidney Transplantation: A Prospective Study. Transplantation Proceedings, 48, (1), 50-54. 6. Terada, I., & Hyde, C. The SF-36: an instrument for measuring quality of life in ESRD patients. Journal of Renal Care. 28, (2), 73-76 7. Beauger D, Gentile S, Jouve E, et al. Analysis, evaluation and adaptation of the ReTransQoL: a specific quality of life questionnaire for renal transplant recipients. Health Qual Life Outcomes. 2013;11(1):1–11. 8. Rostami, Z., Tavallaii, S.A., Jahani, Y., & Einollahi, B. Assessment of quality of life in a single-center transplantation population using the Kidney Transplant Questionnaire-25 questionnaire. Transplantation Proceedings .43, (2), 590-591. 9. Maglakelidze N, Pantsulaia T, Tchokhonelidze I, Managadze L, Chkhotua A. Assessment of health related quality of life in renal transplant recipients and dialysis patients. Transplant Proc.2011;43(1):376–379. 10. Tayebi A.1 MSc, Raiesifar A. MSc, Ebadi A.1 PhD, Eynollahi B.2 MD, Rafiyan Z.1 MSc, Keyvanloo F.1 MSc. Investigation of renal transplantation patients’ quality of life by kidney transplantation questionnaire (KTQ-25). Faculty of Nursing, Baqiyatallah University of Medical Sciences, Tehran, Iran. 11. Yujian Niu1, Wenxin Zhang, Sha Mao, Yanhong Gao, Jianli Wang, Jun Li, Letian Wang, Zhaojie Guan, Zhongyang Shen. Pilot feasibility research of Chinese version of kidney transplant questionnaire in recipients of living donor kidney transplantation 1Institute of Organ Transplantation, The General Hospital of Chinese People’s Armed Police Forces, Beijing 100039, China; December 30, 2015 12. Couser WG, Remuzzi G, Mendis S, Tonelli M. The contribution of chronic kidney disease to the global burden of major no communicable diseases. Kidney Int. Dec 2011; 80(12):1258-1270. 13. Jha V, Garcia-Garcia G, Iseki K, et al. Chronic kidney disease: global dimension and perspectives. Lancet. Jul 20 2013; 382(9888):260-272. 14. World Kidney Day: Chronic Kidney Disease. 2015; http://www.worldkidneyday.org/faqs/chronic-kidney-disease. 15. Janaudis Ferreira Tania, Sapir-pichhadze Ruth, Nzula Sazini, Fiore Julio, Mayo Nancy 2018. Identifying what aspects of the post kidney transplant experience affect quality of life. July 2018 – volume 102 – issue – p S530. 16. Wei, T. Y., Chiang, Y. J., Hsieh, C. Y., Weng, L.C., Lin, S. C., & Lin, M. H. (2013). Health Related Quality of Life of Long-Term Kidney Transplantation Recipients. Biomedical Journal. 36, (5), 243-251. 17. Zheng, X.Y., Han, S., Wang, L.M., Zhu, Y.H., Zeng, L., & Zhou, M.S. (2014). Quality of Life and Psychology After Living-related Kidney Transplantation from Donors and Recipients in China. Transplantation Proceedings. 46, (10), 3426-3430. 18. Tayyebi, A., Raiesifar, A., Najafi, M. S., Ebadi, A., Einolahi, B., & Pashandi, S. (2012). Measuring health related quality of life (HRQOL) in renal transplant patients: psychometric properties and cross-cultural adaptation of kidney transplant questionnaire (ktq-25) in Persian. Nephro-Urology Monthly, 4, (4), 617-621, 19. Momina M. Ahmed, Mahteme Bekele, Engida Abebe, Mekdim Tadesse, Tekleberhan Berhe, BerhanuWorku, Berhane Redae, Zerihun Abebe, Fasika Tedla, Mersema Abate, Deepa Jayaram, Jose Medina Pestana, Lynn Reid, Colleen Satarino, Carly Fritsch, Lia Gebremedhin, SenaitFisseha, Robert Merion, Kenneth Woodside, Alan Leichtman, Jeffrey Punch. Live Donor Kidney Transplantation Outcomes Following Establishment of the First Kidney Transplant Center in Ethiopia. 2017. 20. Bohlke M, Marini SS, Rocha M, et al. Factors associated with health-related quality of life after successful kidney transplantation: a population based study. Qual Life Res. 2009;18(9):1185–1193. 21. Rebollo P, Ortega F, Ortega T, et al. Spanish validation of the “Kidney Transplant Questionnaire”: a useful instrument for assessing health related quality of life in kidney transplant patients. Health Qual Life Outcomes. 2003;1(1):10351039. 22. Haller M, Gutjahr G, Kramar R, Harnoncourt F, Oberbauer R. Cost effectiveness analysis of renal replacement therapy in Austria. Nephrol Dial Transplant. 2011;26(9):29882995.

Background: Kidney Transplant is at its early childhood in Ethiopia, only 3 and half years since the first successful surgery. Surgical outcomes of the donors and recipient is an important parameter to assess the center performance. Objective: Determine socio-demographic characteristics, types of surgery, morbidity and types of complications in the first 100 living kidney donors and recipients in the national transplant center of Ethiopia. Methods: A retrospective review and analysis of medical records of the first 100 living kidney donors and recipients was done. Descriptive statistics on socio-demographic and clinical characteristics of the donors and the patients was performed. Results: The 100 transplants were done in 42 months making an average of 29 transplants a year. Males made 52% of the donors. The mean age of donors was 32.8 years (ranged 20-66 years). Siblings were the main donors 44%. After the first 44 hand assisted laparoscopic donor nephrectomy (HALDN) due to cost of consumables we shifted to open flank incision donor nephrectomy. In HALDN conversion rate was 6.7% (3). All nephrectomies were left side. In 90% of the donors the kidney had one artery. Except one patient who developed small bowel obstruction and needed laparotomy all patients were discharged with smooth post operative course. Only one patient was readmitted for symptomatic retro-peritoneal hematoma which required drainage. Regarding the recipients, male made 70% of the recipients. The age of patients ranged from 16 to 62 with a mean of 33.6. The cause of ESRD was unknown in most patients, 62%. The mean BMI of patients was 20 kg/m2. The average time from out of ice to revascularization was 31.5 minutes. SSSI was the commonest postoperative complication seen in 6%. Except two patients with early graft loss, 98% of patients were discharged with functioning graft. Conclusions: the surgical outcomes of both the donor and the recipient is comparable with centers with long years of experience.

Author(s): Saran, R; Li, Y; Robinson, B; Ayanian, J; Balkrishnan, R; Bragg-Gresham, J; Chen, JTL; Cope, E; Gipson, D; He, K; Herman, W; Heung, M; Hirth, RA; Jacobsen, SS; Kalantar-Zadeh, K; Kovesdy, CP; Leichtman, AB; Lu, Y; Molnar, MZ; Morgenstern, H; Nallamothu, B; Ou0027Hare, AM; Pisoni, R; Plattner, B; Port, FK; Rao, P; Rhee, CM; Schaubel, DE; Selewski, DT; Shahinian, V; Sim, JJ; Song, P; Streja, E; Kurella Tamura, M; Tentori, F; Eggers, PW; Agodoa, LYC; Abbott, KC

BACKGROUND AND OBJECTIVES:Immunosuppressive medications are critical for maintenance of graft function in transplant recipients but can represent a substantial financial burden to patients and their insurance carriers. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS:To determine whether availability of generic immunosuppressive medications starting in 2009 may have alleviated some of that burden, we used Medicare Part D prescription drug events between 2008 and 2013 to estimate the average annualized per-patient payments made by patients and Medicare in a large national sample of kidney, liver, and heart transplant recipients. Repeated measures linear regression was used to determine changes in payments over the study period. RESULTS:Medicare Part D payments for two commonly used immunosuppressive medications, tacrolimus and mycophenolic acid (including mycophenolate mofetil and mycophenolate sodium), decreased overall by 48%-67% across organs and drugs from 2008 to 2013, reflecting decreasing payments for brand and generic tacrolimus (21%-54%), and generic mycophenolate (72%-74%). Low-income subsidy payments, which are additional payments made under Medicare Part D, also decreased during the study period. Out-of-pocket payments by patients who did not receive the low-income subsidy decreased by more than those who did receive the low-income subsidy (63%-79% versus 24%-44%). CONCLUSIONS:The decline in payments by Medicare Part D and by transplant recipients for tacrolimus and mycophenolate between 2008 and 2013 suggests that the introduction of generic immunosuppressants during this period has resulted in substantial cost savings to Medicare and to patients, largely reflecting the transition from brand to generic products.

On July 10, 2019, President Trump and the United States Department of Health and Human Services announced the Advancing American Kidney Health initiative (Table 1). This executive order outlines 3 principal goals and 7 objectives (Table 2). These goals and objectives are comprehensive and well conceived, and if acted upon, they would do much to reduce the tremendous health burdens and costs associated with chronic kidney disease (CKD) and end-stage renal disease (ESRD) in the United States. These goals are accompanied by ambitious specific targets, including a 25% reduction in the number of Americans who develop ESRD by 2030, initiation of home dialysis or transplantation for 80% of new patients with ESRD by 2025, and doubling the number of kidneys available for transplantation by 2030.Table 1Links to additional information elaborating on the Advancing American Kidney Health initiativeLink1Advancing American Kidney Health executive order: https://www.whitehouse.gov/presidential-actions/executive-order-advancing-american-kidney-health/. Accessed August 28, 2019.2Report by the Health and Human Services Assistant Secretary for Planning and Evaluation: https://aspe.hhs.gov/system/files/pdf/262046/AdvancingAmericanKidneyHealth.pdf. Accessed August 28, 2019.3Centers for Medicare and Medicaid Innovation ESRD Treatment Choices Model Web site: https://innovation.cms.gov/initiatives/esrd-treatment-choices-model/. Accessed August 28, 2019.4Centers for Medicare and Medicaid Innovation Voluntary Kidney Models Web site: https://innovation.cms.gov/initiatives/voluntary-kidney-models/. Accessed August 28, 2019.5Proposed rule for the ESRD Treatment Choices Model: https://www.regulations.gov/document?D=CMS-2019-0101-0001. Accessed August 28, 2019.ESRD, end-stage renal disease. Open table in a new tab Table 2Goals and objectives outlined in the July 10, 2019, executive order announcing the national Advancing American Kidney Health initiativeaReport by the Health and Human Services Assistant Secretary for Planning and Evaluation: aspe.hhs.gov/system/files/pdf/262046/AdvancingAmericanKidneyHealth.pdf. Accessed August 28, 2019.GoalAdvancing American Kidney Health: goals and objectives1Reduce the risk of kidney failureOBJECTIVE 1: Advance public health surveillance capabilities and research to improve identification of populations at risk and those in early stages of kidney diseaseOBJECTIVE 2: Encourage adoption of evidence-based interventions to delay or stop progression to kidney failure2Improve access to and quality of person-centered treatment optionsOBJECTIVE 1: Improve care coordination and patient education for people living with kidney disease and their caregivers, enabling more person-centric transitions to safe and effective treatments for kidney failureOBJECTIVE 2: Introduce new value-based kidney disease payment models that align health care provider incentives with patient preferences and improve quality of lifeOBJECTIVE 3: Catalyze the development of innovative therapies including wearable or implantable artificial kidneys with funding from government, philanthropic, and private entities through KidneyX and coordinate regulatory and payment policies to incentivize innovative product development3Increase access to kidney transplantsOBJECTIVE 1: Increase the utilization of available organs from deceased donors by increasing organ recovery and reducing the organ discard rateOBJECTIVE 2: Increase the number of living donors by removing disincentives to donation and ensuring appropriate financial supporta Report by the Health and Human Services Assistant Secretary for Planning and Evaluation: aspe.hhs.gov/system/files/pdf/262046/AdvancingAmericanKidneyHealth.pdf. Accessed August 28, 2019. Open table in a new tab ESRD, end-stage renal disease. Central components of these plans include both the mandatory ESRD Treatment Choices model, which will randomly enroll half of US nephrologists and dialysis facilities, and the voluntary Kidney Care First and Comprehensive Kidney Care Contracting models, which will build on the existing Comprehensive ESRD Care model. These new payment models will operate under traditional Medicare (parts A and B) through the Center for Medicare and Medicaid Innovation. The intent of these payment models is to provide resources and incentives for the management of patients with CKD stages 4 and 5, use of home dialysis therapies, and facilitation of kidney transplantation. These models will be initiated starting on January 1, 2020. Depending on the model, alternative funding approaches will be implemented in 2020 or 2021 and extend through 2023 or 2026. Cost and clinical outcomes resulting from these models will be evaluated and decisions will be taken regarding modification or continuation of these new funding algorithms. A partial list of additional components of the Advancing American Kidney Health initiative include deployment of open-source portable electronic care plan tools for patients with multiple chronic conditions; enhanced education opportunities for patients with kidney disease; development of new diagnostics and therapies through KidneyX, a public-private partnership between the US Department of Health and Human Services and the American Society of Nephrology; new guidance for development of organ preservation technologies; learning collaborative engagement to reduce kidney discard rates, increase organ recovery, and accelerate organ placement; research on the use of donors with HIV, hepatitis C, and the apolipoprotein L1 (APOL1) gene; and expansion of travel, subsistence, and lost wage reimbursement for potential living kidney donors who are in need of such assistance to move forward with donation. Patients with renal disease ultimately may benefit from successful implementation of the incentives, innovations, and practice-pattern changes that these initiatives are designed to enhance. However, it is uncertain whether the nephrology community is resourced and positioned to respond in the short term to many of these new proposed changes. Kidney disease is a public health catastrophe. Risk factors for the development and progression of kidney disease have long been recognized. Despite readily available and effective treatments, poorly controlled diabetes and hypertension are both causes and accelerants of renal insufficiency. Furthermore, kidney disease amplifies the consequences of cardiovascular disease and increases frailty.1United States Renal Data System. Chapter 4: cardiovascular disease in patients with CKD. Available at: https://www.usrds.org/2018/view/v1_04.aspx. Accessed August 28, 2019.Google Scholar CKD is associated with increasing mortality to the extent that substantially fewer Americans have stage 5 than stage 4 CKD, and even fewer have stage 4 when compared with stage 3 CKD, reflecting in part the high and increasing likelihood of death associated with progressive renal diseases. Whereas patients experience few, if any, symptoms until kidney disease is far advanced, criteria for diagnosing and staging chronic kidney disease are well characterized and readily available to providers and payers through direct patient contact and by examination of electronic medical records, laboratory databases, and insurance claims.2United States Renal Data System. Chapter 2: identification and care of patients with CKD. Available at: https://www.usrds.org/2018/view/v1_02.aspx. Accessed August 28, 2019.Google Scholar Yet little has been accomplished previously at national, health system, payer, or individual practice levels to systematically leverage these data to identify and monitor patients with CKD or risk factors for CKD and to implement early diagnosis and interventions. Public education is largely absent. In the United States, late recognition commonly leads to delayed referrals to nephrologists and kidney transplant programs; patients and their families are often incompletely appraised of their options and poorly prepared to choose and begin treatment; and preparations for renal replacement therapies often are hastily arranged and emergent. Consequently, most patients with progressive CKD are funneled toward perpetual in-center hemodialysis.3United States Renal Data System. Chapter 1: incidence, prevalence, patient characteristics, and treatment modalities. Available at: https://www.usrds.org/2018/view/v2_01.aspx. Accessed August 28, 2019.Google Scholar Whereas outcomes in general favor persons who receive early or preemptive kidney transplantation or may be improved in some respects for persons who initiate peritoneal dialysis or home hemodialysis, as opposed to in-center hemodialysis, barriers often exist to implementing these treatment options at the individual patient level, as well as at payer and provider levels. To the extent that ESRD is a disease that disproportionately affects chronically ill and elderly persons, not all patients are suitable for transplantation or home dialysis options. Furthermore, not all patients have social support and the functional capacity necessary to maintain themselves outside of in-center treatment environments. A sizeable minority of older patients and, particularly, frail patients with kidney disease may in fact not benefit from either dialysis or transplantation, instead achieving better quality and duration of life through supportive therapies. Identifying these patients is an emerging challenge to providers of kidney disease care. Workforce, resource, organizational, and financial obstacles facing the Advancing American Kidney Health initiative are considerable. Although it is possible that implementation of this initiative eventually may lead to overall cost savings, it is probable that considerable investment will be needed during the transition from present to future payment models. Current and prior administrative and financial incentives have led most nephrologists to concentrate their practices and expertise on either in-center hemodialysis or on kidney transplantation. Tremendous resources have been invested in in-center hemodialysis, and interests are entrenched. Historically, payment for management of CKD has been low, and because nephrologists often are fully committed to in-center dialysis or transplantation, patients with CKD usually are managed in primary care settings. Absence of engagement by nephrology professionals in turn leads to non–evidence-based and inconsistent care, lack of standardization of interventions to monitor and delay disease progression, failure to engage the patient in choice of treatment options, and a disorderly transition from CKD to ESRD. Furthermore, diagnosis and treatment of patients with kidney disease is complex and frequently requires care during evening and nighttime hours. Nephrologist practice hours are long, and compensation for nephrologists is less than that of procedure-oriented medical subspecialties, such as cardiology and gastroenterology. Consequently, nephrology does not present itself as an attractive career choice to medical students and house officers. Nephrology fellowship programs no longer attract top-tier trainees, and many programs have difficulty filling positions or compromise on background and quality when accepting applicants into their fellowships.4Kidney News OnlineThe impending workforce crisis in nephrology. Available at:.https://www.kidneynews.org/kidney-news/special-sections/special-section/the-impending-workforce-crisis-in-nephrologyGoogle Scholar Consequently, the United States has a shortage of nephrologists, and many are not comprehensively trained in all aspects of the management of CKD and ESRD, including diagnosis of renal and urological diseases, home hemodialysis, in-center hemodialysis, peritoneal dialysis, transplant medicine, and supportive alternative and palliative care.5Berns J.S. A survey-based evaluation of self-perceived competency after nephrology fellowship training.Clin J Am Soc Nephrol. 2010; 5: 490-496Crossref PubMed Scopus (113) Google Scholar Practice settings rarely provide patients with the full range of therapeutic alternatives. Similarly, nephrology office and dialysis administrators, mid-level providers, nurses, social workers, dieticians, and patient educators are not trained to provide and support the full range of CKD and ESRD treatment options. Practices and facilities in US Territories and in rural, isolated, and highly underserved urban areas are presented with especially severe barriers to providing comprehensive kidney care alternatives. Developing resources and training substantial numbers of general nephrologists, staff, and nonphysician providers to offer the entire list of options that ideally would be available to guarantee quality comprehensive treatment for patients with CKD and ESRD will be costly and require investments in personnel and resources and are unlikely to be achieved within the anticipated time frames of the proposed payment models. As shown in Goal 3 and the related objectives from Table 2, increasing kidney transplantation is a critical element of the Advancing American Kidney Health initiatives. Challenges to increasing kidney transplantation include improving access to the waiting list and living donor transplantation, optimizing organ availability, and refining allocation policies. It is well documented that access to live donation and deceased donor kidney transplant waiting lists varies across the United States. Similarly, organ procurement organization performance and transplant center organ acceptance practices are highly variable. Models developed at previous US Department of Health and Human Services–sponsored donation and transplantation collaboratives have demonstrated opportunities for sizably increasing donation and transplantation rates. Adoption of these strategies were compromised by resource limitations, absence of incentives, distrust of adjustment models used to rank organ procurement organizations and transplant programs, and fears that utilization of nontraditional donors might result in unfavorable regulatory organ procurement organization and transplant center performance reviews. Increasing living donor kidney transplantation will be necessary to the aim of “doubling the number of kidneys available for transplantation by 2030.” However, concern for the well-being of the live donor must be the first and foremost consideration in any such expansion. In addition to the pain and anxiety associated with the surgery, living donation is often a financial hardship on the donor and the donor’s family. Expansion of travel, subsistence, and lost wage reimbursement for potential living kidney donors who are in need of such assistance to move forward with donation would be an important contribution to the well-being of many donors and potentially increase opportunities for transplantation for their loved ones and their intended recipients. Multiple proposals to ensure and monitor living donor well-being were developed at a 2011 conference on living donor follow-up. Key among these were calls to fund a scientifically sound, adequately powered, long-term living donor follow-up study and to provide a mechanism by which living donors could self-report late complications arising from donation to the Organ Procurement and Transplantation Network.6Leichtman A. Abecassis M. Barr M. et al.Living kidney donor follow-up: state-of-the-art and future directions.Am J Transplant. 2011; 11: 2561-2568Crossref PubMed Scopus (74) Google Scholar These recommendations should be revisited and acted upon. In addition, one of the important developments for promoting living donor transplantation has been the introduction of kidney paired donation. Adoption of a living donor standard acquisition charge has been proposed to facilitate and provide cost certainty for kidney paired donation across payers and institutions.7Melcher M.L. Blosser C.D. Baxter-Lowe L.A. et al.Dynamic challenges inhibiting optimal adoption of kidney paired donation: findings of a consensus conference.Am J Transplant. 2013; 13: 851-860Crossref PubMed Scopus (44) Google Scholar The Centers for Medicare and Medicaid Services should formally institute this payment mechanism. After nearly 10 years of intense study and negotiation, a new US deceased donor kidney allocation system was adopted in December 2014.8Stegall M.D. Stock P.G. Andreoni K. et al.Why do we have the kidney allocation system we have today? A history of the 2014 kidney allocation system.Hum Immunol. 2017; 78: 4-8Crossref PubMed Scopus (35) Google Scholar This system is an important step forward in allocation policy and has reduced barriers to transplantation for minorities and sensitized transplant candidates. To a limited extent, it also allows for survival matching between donor kidneys and waitlisted candidates with the longest potential for posttransplant survival. However, it has been shown through allocation modeling that, even without increasing the size of the deceased donor pool, tens of thousands of additional posttransplant life years could be obtained from alternative kidney allocation systems that allocate kidneys to maximize incremental posttransplant patient survival.9Wolfe R.A. McCullough K.P. Schaubel D.E. et al.Calculating life years from transplant (LYFT): methods for kidney and kidney-pancreas candidates.Am J Transplant. 2008; 8: 997-1011Crossref PubMed Scopus (149) Google Scholar Consideration of alternative allocation systems that improve the survival potential arising from the deceased donor pool should be reconsidered as efforts focus on increasing opportunities for transplantation. In announcing the Advancing American Kidney Health initiative, the administration emphasized its intent to “shift from paying for sickness and procedures to paying for health and outcomes.” These proposals reflect input from government agencies, patients, patient advocates, providers, professional organizations, dialysis entities, pharmaceutical companies, and device manufacturers. Current funding mechanisms, policies, and practices in renal medicine are far from ideal and poorly serve the patient, payer, and physician communities. As previously described, this initiative is likely to face many challenges, and true reform will require appropriate incentives and new adequately directed resources both during and after the transition from current to future payment models. However, altering the current national kidney care model has the potential to motivate shifts in values, funding, patient care strategies, outcomes, and culture. This initiative deserves the community’s active engagement, participation, and support. All the authors declared no competing interests. The Executive Order on Kidney Care: We Need to Do Much More to Win the Battle Against Kidney DiseaseKidney International ReportsVol. 4Issue 11PreviewMy family is an Alport’s family; as such, I have a lot of experience with end-stage renal disease (ESRD), dialysis, and transplants. There are 7 transplant recipients (9 transplants) among the 20 children of 4 Alport’s siblings. All but 1 received their kidneys from deceased donors. Full-Text PDF Open AccessGeographic Variation in the Availability of Deceased Donor Kidneys per Wait-Listed Candidate in the United StatesKidney International ReportsVol. 4Issue 11PreviewThe burden of end-stage kidney disease is increasing in the United States alongside a worsening shortage of organs for transplantation that is exacerbated by the suboptimal recovery and inappropriate discard of kidneys from deceased donors.1–3 Despite a stated goal of eliminating candidate location as a factor determining likelihood of transplantation, known geographic disparities in access to transplantation have persisted even under the new allocation system.4 The current kidney allocation system first offers deceased donor kidneys to eligible candidates within the donation service area (DSA) where they were recovered, followed by the Organ Procurement and Transplantation Network region, and then finally nationwide. Full-Text PDF Open AccessPredialysis Care Experience Among Patients With CKD at a Teaching Hospital in KenyaKidney International ReportsVol. 4Issue 11PreviewChronic kidney disease (CKD) is a global health problem affecting more than 1 in every 10 of the adult population.1 The leading causes of CKD are diabetes mellitus and hypertension. End-stage kidney disease (ESKD) requires kidney replacement therapy (KRT) for sustenance of bodily functions. The KRT includes kidney transplantation and dialytic therapies. Dialytic therapies include hemodialysis (HD) and peritoneal dialysis. In recent years, the government of Kenya has set up at least one HD unit in each of the country’s 47 counties. Full-Text PDF Open Access2017 Kidney Disease: Improving Global Outcomes (KDIGO) Chronic Kidney Disease–Mineral and Bone Disorder (CKD-MBD) Guideline Update Implementation: Asia Summit Conference ReportKidney International ReportsVol. 4Issue 11PreviewThe Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on Chronic Kidney Disease–Mineral and Bone Disorder (CKD–MBD) 2009 provided recommendations on the detection, evaluation, and treatment of CKD-MBD in patients CKD who are and are not undergoing dialysis. Because of the accumulation of evidence since this initial publication, the CKD-MBD Guideline underwent a selective update in 2017. In April 2018, KDIGO convened a CKD-MBD Guideline Implementation Summit in Japan with the key objective to discuss various barriers to the uptake and implementation of the CKD-MBD Guideline in 8 Asian countries/regions. Full-Text PDF Open AccessAssociation Between Perfluoroalkyl Substance Exposure and Renal Function in Children With CKD Enrolled in H3Africa Kidney Disease Research NetworkKidney International ReportsVol. 4Issue 11PreviewThe prevalence of chronic kidney disease (CKD) is increasing at an accelerated pace in countries with limited health resources compared to developed countries.1 There is a need for more studies of the epidemiology and clinical characteristics of CKD in pediatric populations in sub-Saharan Africa, where risk factors are common.2 Full-Text PDF Open Access

Background and objectivesThe aim in kidney paired donation (KPD) is typically to maximize the number of transplants achieved through the exchange of donors in a pool comprising incompatible donor-candidate pairs and non-directed (or altruistic) donors. With many possible options in a KPD pool at any given time, the most appropriate set of exchanges cannot be determined by simple inspection. In practice, computer algorithms are used to determine the optimal set of exchanges to pursue. Here, we present our software application, KPDGUI (Kidney Paired Donation Graphical User Interface), for management and optimization of KPD programs.MethodsWhile proprietary software platforms for managing KPD programs exist to provide solutions to the standard KPD problem, our application implements newly investigated optimization criteria that account for uncertainty regarding the viability of selected transplants and arrange for fallback options in cases where potential exchanges cannot proceed, with intuitive resources for visualizing alternative optimization solutions.ResultsWe illustrate the advantage of accounting for uncertainty and arranging for fallback options in KPD using our application through a case study involving real data from a paired donation program, comparing solutions produced under different optimization criteria and algorithmic priorities.ConclusionsKPDGUI is a flexible and powerful tool for offering decision support to clinicians and researchers on possible KPD transplant options to pursue under different user-specified optimization schemes.