Jaume Tort

Starting hemodialysis with catheter and mortality risk: persistent association in a competing risk analysis.

Purpose The vascular access (VA) used at hemodialysis (HD) inception is involved in the mortality risk. We analyzed the survival of incident patients over time according to the initial VA and the VA profile of patients who died during the first year of follow-up. Methods Data of VA were obtained from 9956 incident HD patients from the Catalan Registry. Results Over 12 years, 47.9% of patients initiated HD with a fístula, 1.2% with a graft, 15.9% with a tunneled catheter and 35% with an untunneled catheter. Regarding fistula use, the hazard ratio of death for all-causes over time when applying a multivariate competing risk model was 1.55 [95% confidence interval (CI): 1.42-1.69] and 1.43 (95% CI: 1.33-1.54) for patients with tunneled and untunneled catheter, respectively. During the first year of follow-up, the crude all-cause mortality rate (deaths/100 patient-years) was higher during the early (first 120 days) compared to the late (121-365 days) period: 18.3 (95% CI: 16.8-19.8) versus 15.4 (95% CI: 14.5-16.5). Regarding fistula use, for patients using untunneled and tunneled catheter, the odds ratio of death in the early period for all-causes was 3.66 (95% CI: 2.80-4.81) and 2.97 (95% CI: 2.17-4.06), for cardiovascular causes it was 2.76 (95% CI: 1.90-4.01) and 1.84 (95% CI: 1.17-2.89) and for infection-related causes it was 6.62 (95% CI: 3.11-14.05) and 4.58 (95% CI: 2.00-10.52), respectively. Conclusions Half of all incident patients in Catalonia are exposed to excessive mortality risk related to catheter and this scenario can be improved by early fistula placement.

Vascular access for incident hemodialysis patients in Catalonia: analysis of data from the Catalan Renal Registry (2000-2011).

Purpose Arteriovenous fístula is the best vascular access (VA) for hemodialysis. We analyzed the VA used at first session and the factors associated with the likelihood to start hemodialysis by fistula in 2000-2011. Methods Data of VA type were obtained in 9,956 incident hemodialysis patients from the Catalan Registry. Results Overall, 47.9% of patients initiated hemodialysis with a fistula, 1.2% with a graft, 15.9% with a tunneled catheter and 35% with an untunneled catheter. The percentage of incident patients with fistula and catheter has remained stable at around 50% over the years. The likelihood to start hemodialysis with fistula was significantly lower in females [adjusted odds ratio: 0.69, 95% confidence interval (CI): 0.61-0.75], patients aged 18-44 years (0.78, 95% CI: 0.64-0.94), patients with comorbidity (0.67, 95% CI: 0.60-0.75) and tended to be lower in patients aged over 74 years (0.89, 95% CI: 0.78-1.01). The probability to use fistula was significantly higher in patients with polycystic kidney disease (2.08, 95% CI: 1.63-2.67), predialysis nephrology care longer than 2 years (4.14, 95% CI: 3.63-4.73) and steady chronic kidney disease (CKD) progression (10.97, 95% CI: 8.41-14.32). During 1 year of follow-up, 67.2% and 59.6% of patients using untunneled and tunneled catheter changed to fistula, respectively. Conclusions Starting hemodialysis by fistula was related with nonmodifiable patient characteristics and modifiable CKD practice processes, such as predialysis care duration. Half of the incident patients were exposed annually in Catalonia to potential catheter complications. This scenario can be improved by optimizing the processes of CKD care.

Attitudes and Knowledge About Donation in Catalonia

Introduction The Catalan Transplant Organization (OCATT) is the public organism of the Catalan Government responsible for planning, ordering, coordinating and assessing all the activities related to donation and transplantation of organs, tissues and cells in Catalonia since 1984. The objective of this study was to describe the attitudes and knowledge about donation in a representative survey in Catalonia in 2016. Methods Data were obtained from the Health Survey of Catalonia (ESCA), a personal interview about health self-perception, lifestyle or use of health services, carried out to a representative sample of 2500 Catalan people. The survey introduced, during the first six months of 2016, seven questions intended to assess the attitudes and knowledge about organ donation. We collected 1,750 surveys (people over 17 years old and not institutionalized) with information about donation. Questions were related with personnel situation about donation, Reasons for to be or not to be donor, shared donor decision, or knowledge about how to be a donor. From these questions we extract information about favourable attitude, effective donation and knowledge. We analysed this items according to some sociodemographic variables and we have also analyzed this data through a multivariate analysis using logistic regression. All the analyses were performed with SPSS 18. Results In Catalonia, 80% of people were in favor of donation. We observed some significance differences according sex, age group, level of studies, self-perception health or country origin. Solidarity and altruism is the main reason (90.8%) for to be donor in people in favor of donation. Meanwhile 38% of people not in favor of donation don’t know or don’t say the reason, followed by the reason they thought their organs were not valid (15.2%). 36.7% of respondents shared with their relatives their own decision about to be donor, but only 1.5% have the donor card. 46% of people would donate the organs without knowing the opinion of deceased person, 87% would respect the decision of deceased person and 70% didn’t know how to become a donor, with significant differences according some sociodemographic variables. Conclusion Although in Catalonia the percentage of people in favor of donation is very high, the donor rate is near to 42 donors per million of population and the percentage of family refusals (15%) is lower than in other countries, campaigns of donation and transplantation promotion must be carried out in the future, if we want to increase our results even more. ESCA professionals. Figure. No caption available. Figure. No caption available. Figure. No caption available.

Evaluation of a Deceased Donor Kidney Allocation Score. The Catalan Experience

Introduction Several countries have implemented their own kidney allocation policies to ensure the equity, transparency and patient benefit in the waiting list. In Catalonia, a new allocation model has been implemented during 2017, which uses a score developed to prioritize the recipients. Four analyses were designed to evaluate that score: 1. Concordance retrospective analysis: would that score have chosen the same recipient as the clinician did in the past? 2. Impact retrospective analysis: how would the recipient profile have changed if the new allocation model were applied in the past? 3. Prospective analysis: Has the concordance changed after providing the score only for information? Which are the causes for not choosing the recipients with higher scores? 4. Evaluation analysis: Has the concordance and patient profile changed after the new allocation model?. Methods Data from the registries of the Catalan Transplant Organization were used. The effective kidney offers from January 2014 to June 2016 and the daily recipients active on the deceased donor renal waiting list were considered for retrospective concordance (n=955) and impact analysis (n=1.046). The effective kidney offers from December 2016 to March 2017 were used for the prospective analysis (n=98). The recipients from the beginning of the new model (12th June 2017) to 31st October 2017 were used to evaluate it (n=208)*. Results RIn the concordance analysis, 282 (29.5%) kidney transplants (KT) were performed to a patient within the top 25th percentile values of the score (concordance). In the impact analysis, comparing the 1.046 KT performed with the 1.046 theoretical KT that would be performed using the new allocation model, we observe an increase of mean time on dialysis (from 36.3 to 57.2 months) and cpra I+II mean (from 51.6% to 64.9%), a decrease of the mean age from 59.2 to 57.9 years and a reduction of first KT from 89.2% to 76.2%. In the 98 KT studied in the prospective analysis, concordance increased up to 65.3%. The main causes for not choosing the recipients with higher values were the disagreement with the candidate (50.3%), immunologic causes (13.2%) and mistakes with the status of the recipient (21.9%). After the implementation of the new model the concordance remained at 65.8%. The mean time on dialysis was 53.5 months, the mean cpra I+II% was 33.8 and the mean age was 57,4 years. Conclusion Although the concordance between the clinician and the developed score was initially low, it increased significantly after providing the waiting list sorted by that score. Changes in the recipient profile observed in the impact analysis were the expected and desired ones. Finally, after the implementation we observe the expected increase of time on dialysis and younger recipients meanwhile the mean of cpra I+II % was lower than expected. * The results will be updated using recipients up to March 2018 in the presentation at 27th International Congress of The Transplantation Society.

Effect of Body Weight Variation in Kidney Transplantation: A Retrospective Cohorts Study.

Introduction Obese kidney allograft recipients have an increased risk of surgical complications, delayed graft function(DGF), prolonged hospital stay and late graft failure. However, there is lack of information regarding the effect of body mass index(BMI) variation after kidney transplantation(KT). Methods and Materials In this longitudinal study, we used data from Catalan Renal Registry including first KT recipients within 1990 and 2011. The annual change on post-transplantation BMI was calculated all patient follow-up (until December 2015). Main outcome variables were DGF, eGFR(CKD-EPI), patient and graft survival. Statistical analysis was adjusted for variables impacting on outcome. Results A total of 5,983 kidney trasnplant recipients were included. Obesity was observed in 609 patients(10.9%) at the time of transplantation. Obese patients were transplanted more recently, were younger and received kidneys from younger donors. Incidence of DGF was significantly higher in obese (40.38% vs 29.5%, P<0.001). Multivariate logistic regression model confirmed that baseline obesity was a risk factor for DGF (class I obesity: OR 1.6; 95%CI 1.3-2.1, P<0.001 and class II OR 2.2; 95%CI 1.5-3.2, P<0.001) whereas under-weight was protective (OR 0.5; 95%CI 0.3-0.8, P=0.005). Moreover, baseline obesity was a detrimental factor concerning long-term graft survival (SHR 1.25; 95%CI 1.03-1.51, P<0.05) without any effect on patient survival (SHR 0.93 95%CI 0.74-1.17, P= 0.53). In obese patients with functioning graft, BMI loss of >7% was associated with better patient survival, and a BMI loss of >7% was associated with worse graft survival. Conclusion Our conclusion is that BMI reduction after KT was not associated with eGFR improvement and only in those with a reduction of >7% patient survival was better with worse long-term graft survival.

New Strategy for Deceased Organ Donor Serology Testing Following two Serious Adverse Occurrences

Introduction In 1984 the Catalan Transplant Organisation (OCATT) was established to plan, manage and coordinate activities related to organ and tissue donation and transplantation. In recent years, vigilance and surveillance (V&S) activities have been implemented as a transverse process throughout the organization. Materials and Methods V&S programs are essential to improve quality and safety for organ transplantation. Adverse events are rare but reporting any incidents are a key part of the V&S system, facilitating the detection of residual risks or unexpected errors that can lead to a severe adverse occurrence (SAO). There are many different factors that can challenge effective SAO reporting, such as lack of detection, lack of well-identified responsibilities, time constraints for investigation or a blame culture among professionals. Other factors may influence the process in a positive way, e.g. clear and user-friendly V&S protocols, in-hospital trained vigilance coordinators and an efficient vigilance office that coordinates V&S. The experience presented is an example of how sharing the investigation of two cases of SAO disease transmission may result in an in-depth review of the deceased donor’s serology screening characterization and the analysis of new emerging disease risks in a donor population. Results Two SAO related to new emerging disease transmissions were reported to the OCATT vigilance office. Both cases had a score of 15 after applying a V&S impact matrix that ranges from 1 to 20, taking severity and probability of recurrence into account. The notification centres implemented a series of corrective actions, addressing internal procedures, governance structure, personnel and organizational issues. The health authority designated a multidisciplinary task force of experts (microbiologists, transplant coordinators, blood and tissue bank, vigilance office and infectious disease) to analyze the donor serology tests and any newly identified risks (Figure1). The group analysed the risks and a new organ donor serology screening strategy was proposed (Figure 2). To detect risks among organ donors a new specifically oriented questionnaire has been developed; a strategic screening has been advised and reference microbiology labs will make available the techniques that will give reliable results. Conclusions Procurement organizations and transplant communities reporting SAO to V&S programs are crucial to improve recipient’s safety. Health authorities have to organize well structured V&S systems to promote reporting, investigation in the context of a no blame culture. In this case, two SAO reports resulted in the establishment of a multidisciplinary task force to analyze organ donor serology screening and new emerging disease risks in the region. New proposals for organ donor serology screening covering all the different risks detected should decrease still more, the risk of potential disease transmission to the recipient community.

Attitudes and Knowledge About Donation in a Representative Survey of Catalan Population

Introduction The Catalan Transplant Organization (OCATT) is the public organism of the Catalan Government responsible for planning, ordering, coordinating and assessing all the activities related to donation and transplantation of organs, tissues and cells in Catalonia since 1984. The objective of this study was to describe the attitudes and knowledge about donation in a representative survey in Catalonia in 2016. Methods Data were obtained from the Health Survey of Catalonia (ESCA), a personal interview about health self-perception, lifestyle or use of health services, carried out to a representative sample of 2500 Catalan people. The survey introduced, during the first six months of 2016, seven questions intended to assess the attitudes and knowledge about organ donation. We collected 1,750 surveys (people over 17 years old and not institutionalized) with information about donation. Question were related with personnel situation about donation, Reasons for to be or not to be donor, shared donor decision, or knowledge about how to be a donor. From these questions, we extract information about favourable attitude, effective donation and knowledge. We analysed this items according to some sociodemographic variables and we have also analyzed this data through a multivariate analysis using logistic regression. All the analyses were performed with SPSS 18. Results In Catalonia, 80% of people were in favor of donation. We observed some significance differences according sex, age group, level of studies, self-perception health or country origin. Solidarity and altruism is the main reason (90.8%) for to be donor in people in favor of donation. Meanwhile 38% of people not in favor of donation don’t know or don’t say the reason, followed by the reason they thought their organs were not valid (15.2%). 36.7% of respondents shared with their relatives their own decision about to be donor, but only 1.5% have the donor card. 46% of people would donate the organs without knowing the opinion of deceased person, 87% would respect the decision of deceased person and 70% didn’t know how to become a donor, with significant differences according some sociodemographic variables. Conclusion Although in Catalonia the percentage of people in favor of donation is very high, the donor rate is near to 42 donors per million of population and the percentage of family refusals (15%) is lower than in other countries, campaigns of donation and transplantation promotion must be carried out in the future, if we want to increase our results even more.

Death of recipients after kidney living donation triples donors’ risk of dropping out from follow-up: a retrospective study

Although kidney transplantation from the donation of a living donor is a safe treatment for end‐stage renal disease, inferences about safety of living kidney donors might be biased by an informative censoring caused by the noninclusion of a substantial percentage of donors lost to follow‐up. With the aim of assessing the presence of a potential informative censoring in living kidney donation outcomes of Catalan donors for a period of 12 years, 573 donors followed and lost to follow‐up were compared. Losses of follow‐up over time were also assessed by univariate and multivariate survival analysis, along with Cox regression. Younger and older ages, and the death of their recipient differentiated those donors who were lost to follow‐up over time. The risk of dropping out from follow‐up was more than twofold for the youngest and oldest donors, and almost threefold for those donors whose recipient died. Results of studies on postdonation outcomes of Catalan living kidney donors might have overlooked older and younger cases, and, remarkably, a percentage of donors whose recipient died. If these donors showed a higher incidence of psychological problems, conclusions about living donors’ safety might be compromised thus emphasizing the necessity of sustained surveillance of donors and prompt identification of these cases.