Etiology
Live kidney donation was associated with increased mortality and end-stage renal disease at 15 years
Mjoen G, Hallan S, Hartmann A, et al. Long-term risks for kidney donors. Kidney Int. 2013 Nov 27. [Epub ahead of print]
Clinical impact ratings: F ★★★★★✩✩ n ★★★★★★★★ Question
Source of funding: Norwegian Extrafoundation.
Do live kidney donors have an increased long-term risk for mortality or end-stage renal disease (ESRD) compared with nondonors who would have met eligibility for donation?
For correspondence: Dr. H. Holdaas, Oslo University Hospital, Oslo, Norway, E-mail [email protected]. ■
Commentary
Methods Design: Comparison of a retrospective cohort of living kidney donors (Oslo University Hospital, Oslo, Norway, 1963 to 2007), with a median follow-up of 15 years (95% CI 1.5 to 44), and a matched control cohort of healthy nondonors identified from a population-based survey (1984 to 1987), with a median follow-up of 25 years (CI 0.1 to 26). Setting: Norway. Patients: 1901 living kidney donors, 20 to 70 years of age (mean age 46 y, 59% women, 100% white, 1519 first-degree relatives of transplant recipients, 89 other relatives, 293 unrelated). Exclusion criteria were antihypertensive medication, blood pressure (BP) > 140/90 mm Hg, body mass index (BMI) > 30 kg/m2, macroalbuminuria, or estimated glomerular filtration rate < 70 mL/min/ 1.73 m2. The control cohort comprised 32 621 matched, healthy nondonors ≥ 20 years of age (mean age 38 y, 53% women) with self-reported “good” or “excellent” health, BP ≤ 140/90 mm Hg, and BMI ≤ 30 kg/m2. Exclusion criteria were diabetes, cardiovascular (CV) disease, use of antihypertensive medication, or reduced general health. Risk factors: Live kidney donation. Outcomes: All-cause mortality, CV mortality (excluding sudden death), and ESRD receiving long-term dialysis or kidney transplantation.
Main results Live kidney donation was associated with increased risk for all-cause mortality, CV mortality, and ESRD (Table).
Conclusion Live kidney donation was associated with increased risk for mortality and end-stage renal disease at a median 15 years after donation. Association between live kidney donation and mortality or end-stage renal disease* Outcomes
Event rates (n)
All-cause mortality
Live kidney donors (n = 1901)
Healthy nondonors (n = 32 621)
12% (224)
7.4% (2425)
Adjusted HR (95% CI)†
1.30 (1.11 to 1.52)
Cardiovascular mortality
3.6% (68)
2.1% (688)
1.40 (1.03 to 1.91)
End-stage renal disease
0.47% (9)
0.06% (22)
11.38 (4.37 to 29.63)
*HR = hazard ratio; other abbreviations defined in Glossary. Median follow-up was 15 y for kidney donors and 25 y for healthy nondonors. †Adjusted for age, sex, year of inclusion, and after multiple imputation and further adjustments for missing data for systolic blood pressure, smoking, and body mass index.
JC12
© 2014 American College of Physicians
Kidney failure is a terrible disease. Compared with dialysis, kidney transplantation improves the length and quality of the recipient’s life. An inadequate supply of kidneys from deceased donors means that 27 000 living kidney donor transplantations are performed worldwide each year (1). The donor, the recipient, and the transplantation team must all believe that the overall benefits of transplantation outweigh any long-term risks to the donor. 4 previous studies of ≥ 1000 donors compared with nondonor controls were reassuring and reported no increased risk for long-term mortality, ESRD, or major adverse CV events after donation (2, 3). The Norwegian study by Mjoen and colleagues adds to the 2 recent American studies, which report a relative 10-fold increase in risk for ESRD in living kidney donors compared with nondonor controls (4, 5). The Norwegian study also found increased risks for all-cause and CV mortality. All 3 studies have limitations; for the Norwegian study, these include differences in the years of accrual between donors and nondonors and differences in baseline age, possibly not offset by statistical adjustment. Nonetheless, consistent results across the 3 studies now leave it indefensible not to disclose the risk for ESRD as part of the informed consent process and emphasize the importance of surveillance and lifestyle choices to keep kidney donors in good health. For risk communication, more work is needed to accurately describe the “lifetime” absolute incidence of ESRD in an easily understood way. Given the recent estimates by Mjoen and others, this may approach 1 in 150 (vs the expected 1 in 1500) in a 60year-old donor and may be as high as 1 in 50 (vs the expected 1 in 500) in a 20-year-old donor (assuming a rate of 330/1 000 000 person-y; that the risk is linear as someone ages [which it may not be]; and that all donors live to the age of 80 y). This new information (and its remaining uncertainty) does not reduce our support for living kidney donation, but it does highlight the real risks faced by donors, including the uncommon tragic outcome of a living kidney donor who later develops kidney failure. Amit X. Garg, MD, PhD Western University London, Ontario, Canada Neil Boudville, MD University of Western Australia Perth, Western Australia, Australia References 1. Horvat LD, Shariff SZ, Garg AX; Donor Nephrectomy Outcomes Research (DONOR) Network. Kidney Int. 2009;75:1088-98. 2. Garg AX, Meirambayeva A, Huang A, et al; Donor Nephrectomy Outcomes Research Network. BMJ. 2012;344:e1203. 3. Reule S, Matas A, Ibrahim HN. Am J Kidney Dis. 2013;61:194-6. 4. Reese PR, Bloom RD, Feldman HI. J Am Soc Nephrol. 2013;24:71A. 5. Muzaale AD, Massie AB, Wang MC, et al. JAMA. 2014;311:579-86.
20 May 2014 | ACP Journal Club | Volume 160 • Number 10
Downloaded From: https://annals.org/pdfaccess.ashx?url=/data/journals/aim/930210/ by a Universite Laval Biblioteque User on 07/31/2017
Live kidney donation was associated with increased mortality and end-stage renal disease at 15 years
Mjoen G, Hallan S, Hartmann A, et al. Long-term risks for kidney donors. Kidney Int. 2013 Nov 27. [Epub ahead of print]
Clinical impact ratings: F ★★★★★✩✩ n ★★★★★★★★ Question
Source of funding: Norwegian Extrafoundation.
Do live kidney donors have an increased long-term risk for mortality or end-stage renal disease (ESRD) compared with nondonors who would have met eligibility for donation?
For correspondence: Dr. H. Holdaas, Oslo University Hospital, Oslo, Norway, E-mail [email protected]. ■
Commentary
Methods Design: Comparison of a retrospective cohort of living kidney donors (Oslo University Hospital, Oslo, Norway, 1963 to 2007), with a median follow-up of 15 years (95% CI 1.5 to 44), and a matched control cohort of healthy nondonors identified from a population-based survey (1984 to 1987), with a median follow-up of 25 years (CI 0.1 to 26). Setting: Norway. Patients: 1901 living kidney donors, 20 to 70 years of age (mean age 46 y, 59% women, 100% white, 1519 first-degree relatives of transplant recipients, 89 other relatives, 293 unrelated). Exclusion criteria were antihypertensive medication, blood pressure (BP) > 140/90 mm Hg, body mass index (BMI) > 30 kg/m2, macroalbuminuria, or estimated glomerular filtration rate < 70 mL/min/ 1.73 m2. The control cohort comprised 32 621 matched, healthy nondonors ≥ 20 years of age (mean age 38 y, 53% women) with self-reported “good” or “excellent” health, BP ≤ 140/90 mm Hg, and BMI ≤ 30 kg/m2. Exclusion criteria were diabetes, cardiovascular (CV) disease, use of antihypertensive medication, or reduced general health. Risk factors: Live kidney donation. Outcomes: All-cause mortality, CV mortality (excluding sudden death), and ESRD receiving long-term dialysis or kidney transplantation.
Main results Live kidney donation was associated with increased risk for all-cause mortality, CV mortality, and ESRD (Table).
Conclusion Live kidney donation was associated with increased risk for mortality and end-stage renal disease at a median 15 years after donation. Association between live kidney donation and mortality or end-stage renal disease* Outcomes
Event rates (n)
All-cause mortality
Live kidney donors (n = 1901)
Healthy nondonors (n = 32 621)
12% (224)
7.4% (2425)
Adjusted HR (95% CI)†
1.30 (1.11 to 1.52)
Cardiovascular mortality
3.6% (68)
2.1% (688)
1.40 (1.03 to 1.91)
End-stage renal disease
0.47% (9)
0.06% (22)
11.38 (4.37 to 29.63)
*HR = hazard ratio; other abbreviations defined in Glossary. Median follow-up was 15 y for kidney donors and 25 y for healthy nondonors. †Adjusted for age, sex, year of inclusion, and after multiple imputation and further adjustments for missing data for systolic blood pressure, smoking, and body mass index.
JC12
© 2014 American College of Physicians
Kidney failure is a terrible disease. Compared with dialysis, kidney transplantation improves the length and quality of the recipient’s life. An inadequate supply of kidneys from deceased donors means that 27 000 living kidney donor transplantations are performed worldwide each year (1). The donor, the recipient, and the transplantation team must all believe that the overall benefits of transplantation outweigh any long-term risks to the donor. 4 previous studies of ≥ 1000 donors compared with nondonor controls were reassuring and reported no increased risk for long-term mortality, ESRD, or major adverse CV events after donation (2, 3). The Norwegian study by Mjoen and colleagues adds to the 2 recent American studies, which report a relative 10-fold increase in risk for ESRD in living kidney donors compared with nondonor controls (4, 5). The Norwegian study also found increased risks for all-cause and CV mortality. All 3 studies have limitations; for the Norwegian study, these include differences in the years of accrual between donors and nondonors and differences in baseline age, possibly not offset by statistical adjustment. Nonetheless, consistent results across the 3 studies now leave it indefensible not to disclose the risk for ESRD as part of the informed consent process and emphasize the importance of surveillance and lifestyle choices to keep kidney donors in good health. For risk communication, more work is needed to accurately describe the “lifetime” absolute incidence of ESRD in an easily understood way. Given the recent estimates by Mjoen and others, this may approach 1 in 150 (vs the expected 1 in 1500) in a 60year-old donor and may be as high as 1 in 50 (vs the expected 1 in 500) in a 20-year-old donor (assuming a rate of 330/1 000 000 person-y; that the risk is linear as someone ages [which it may not be]; and that all donors live to the age of 80 y). This new information (and its remaining uncertainty) does not reduce our support for living kidney donation, but it does highlight the real risks faced by donors, including the uncommon tragic outcome of a living kidney donor who later develops kidney failure. Amit X. Garg, MD, PhD Western University London, Ontario, Canada Neil Boudville, MD University of Western Australia Perth, Western Australia, Australia References 1. Horvat LD, Shariff SZ, Garg AX; Donor Nephrectomy Outcomes Research (DONOR) Network. Kidney Int. 2009;75:1088-98. 2. Garg AX, Meirambayeva A, Huang A, et al; Donor Nephrectomy Outcomes Research Network. BMJ. 2012;344:e1203. 3. Reule S, Matas A, Ibrahim HN. Am J Kidney Dis. 2013;61:194-6. 4. Reese PR, Bloom RD, Feldman HI. J Am Soc Nephrol. 2013;24:71A. 5. Muzaale AD, Massie AB, Wang MC, et al. JAMA. 2014;311:579-86.
20 May 2014 | ACP Journal Club | Volume 160 • Number 10
Downloaded From: https://annals.org/pdfaccess.ashx?url=/data/journals/aim/930210/ by a Universite Laval Biblioteque User on 07/31/2017
