Publications by authors named "Germaine Wong"

289 Publications

Kidney transplant recipient perspectives on telehealth during the COVID-19 pandemic.

Transpl Int 2021 Jun 11. Epub 2021 Jun 11.

Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia.

Background: The COVID-19 pandemic has challenged the delivery of health services. Telehealth allows delivery of care without in-person contacts and minimizes the risk of vial transmission. We aimed to describe the perspectives of kidney transplant recipients on the benefits, challenges and risks of telehealth.

Methods: We conducted five online focus groups with 34 kidney transplant recipients who had experienced a telehealth appointment. Transcripts were thematically analyzed.

Results: We identified five themes: minimizing burden (convenient and easy, efficiency of appointments, reducing exposure to risk, limiting work disruptions, alleviating financial burden); attuning to individual context (depending on stability of health, respect patient choice of care, ensuring a conducive environment); protecting personal connection and trust (requires established rapport with clinicians, hampering honest conversations, diminished attentiveness without incidental interactions, reassurance of follow up, missed opportunity to share lived experience); empowerment and readiness (increased responsibility for self-management, confidence in physical assessment, mental preparedness, forced independence); navigating technical challenges (interrupted communication, new and daunting technologies, cognisant of patient digital literacy).

Conclusions: Telehealth is convenient and minimizes time, financial and overall treatment burden. Telehealth should ideally be available after the pandemic, be provided by a trusted nephrologist and supported with resources to help patients prepare for appointments.
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http://dx.doi.org/10.1111/tri.13934DOI Listing
June 2021

Jurisdictional inequalities in deceased donor kidney allocation in Australia.

Kidney Int 2021 Jul 5;100(1):49-54. Epub 2021 May 5.

Sydney School of Public Health, University of Sydney, Camperdown, New South Wales, Australia; Centre for Kidney Research, Kids Research Institute, The Children's Hospital at Westmead, Sydney, New South Wales, Australia; Centre for Transplant and Renal Research, Westmead Hospital, Sydney, New South Wales, Australia. Electronic address:

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http://dx.doi.org/10.1016/j.kint.2021.04.028DOI Listing
July 2021

Qualitative research methods and its application in nephrology.

Nephrology (Carlton) 2021 May 5. Epub 2021 May 5.

Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia.

Chronic kidney disease is associated with an increased risk of mortality, comorbidities and life-threatening complications. Invasive treatments including dialysis or transplantation, complex pharmacological therapies, dietary restrictions and the ongoing need to attend follow-up appointments can place a substantial treatment burden on patients and carers and impair quality of life. This highlights the need for care that is responsive to the needs of patients and involves them in decision-making to achieve the most appropriate healthcare outcomes. Shared decision-making and collaborative approaches to care require a deep awareness of the lived experiences and goals of patients. Qualitative research methods can provide insights into patients' experiences, values and priorities and inform practice and policy by uncovering their preferences for care. Qualitative methods are increasingly being used in standalone projects or in mixed methods studies (complementing quantitative studies) to make valuable contributions to patient-centred research. Patient-centred care, collaborations between patient and care provider, and shared decision-making that integrates with the patient's goals are central to quality healthcare. The efficacy of qualitative research lies in its ability to elicit patients' perspectives, values, priorities and goals that underpin shared decision making and care. This article discusses examples of how qualitative research has informed practice and policy in nephrology, provides a summary of qualitative research methods and outlines a guide on how to appraise, interpret and apply qualitative data.
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http://dx.doi.org/10.1111/nep.13888DOI Listing
May 2021

Paediatric deceased donor kidney transplant in Australia: A 30-year review-What have paediatric bonuses achieved and where to from here?

Pediatr Transplant 2021 May 4:e14019. Epub 2021 May 4.

Department of Nephrology, Sydney Children's Hospital, Randwick, NSW, Australia.

Background: In this 30-year national review, we describe trends in DD transplantation for paediatric recipients, assess the impact of paediatric allocation bonuses and identify outstanding areas of need for this population.

Methods: A retrospective review of all DD kidney only transplants to paediatric recipients (<18 years old) in Australia between 1989 and 2018 was conducted using deidentified extracts from the ANZDATA.

Results: Of the 1011 kidney only transplants performed in paediatric recipients during the study period, 426 (42%) were from deceased donors. Paediatric candidates on the DD waiting list had consistently higher rates of transplantation and shorter time from dialysis initiation to transplantation compared with adult candidates (median 372 vs 832 days in 2018, for example). Donor characteristics remained more favourable for paediatric recipients, despite a decline in the overall quality of the donor pool. The mean number of HLA antigen mismatches for paediatric recipients of DD transplants increased each decade (2.86 [1989-1998], 3.85 [1999-2008], 4.01 [2009-2018]). Both patient and graft survival have improved for paediatric DD transplant recipients in the most recent era (5-year graft and patient survival 85% vs 65% and 99% vs 94%, respectively, for 2009-2018 vs 1999-2008).

Conclusions: The current DD kidney allocation system in Australia provides rapid access to high-quality organs for paediatric recipients, and early graft loss has decreased significantly in recent years; however, additional targeted interventions to address HLA matching may improve long-term outcomes in this population.
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http://dx.doi.org/10.1111/petr.14019DOI Listing
May 2021

Polyoma BK Virus in Kidney Transplant Recipients: Screening, Monitoring and Management.

Transplantation 2021 Apr 27. Epub 2021 Apr 27.

Sydney School of Public Health, University of Sydney, New South Wales, Australia John Hunter Hospital, Newcastle, New South Wales, Australia Centre for Transplant and Renal Research, Department of Renal Medicine, Westmead Hospital, Westmead, New South Wales, Australia Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, New South Wales, Australia.

Polyomavirus BK virus (BKPyV) infection is an important complication of kidney transplantation and allograft failure. The prevalence of viremia is 10-15%, compared with BK associated nephropathy (BKPyVAN) at 3-5%. Given that there are no effective anti-viral prophylaxis or treatment strategies for BKPyVAN, active screening to detect BKPyV viraemia is recommended, particularly during the early post-transplant period. Immunosuppression reduction to allow viral clearance may avoid progression to severe and irreversible allograft damage. The frequency and duration of screening are highly variable between transplant centers because the evidence is reliant largely on observational data. Whilst the primary treatment goals center on achieving viral clearance through immunosuppression reduction, prevention of subsequent acute rejection, premature graft loss and return to dialysis remain as major challenges. Treatment strategies for BKPyV infection should be individualised to the recipient's underlying immunological risk and severity of the allograft infection. Efficacy data for adjuvant therapies including intravenous immunoglobulin and cidofovir are sparse. Future well-powered and high-quality randomized controlled trials are needed to inform evidence-based clinical practice for the management of BKPy infection.
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http://dx.doi.org/10.1097/TP.0000000000003801DOI Listing
April 2021

Perspectives of solid organ transplant recipients on medicine-taking: Systematic review of qualitative studies.

Am J Transplant 2021 Apr 18. Epub 2021 Apr 18.

Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia.

Medicine-taking among transplant recipients is a complex and ubiquitous task with significant impacts on outcomes. This study aimed to describe the perspectives and experiences of medicine-taking in adult solid organ transplant recipients. Electronic databases were searched to July 2020, and thematic synthesis was used to analyze the data. From 119 studies (n = 2901), we identified six themes: threats to identity and ambitions (impaired self-image, restricting goals and roles, loss of financial independence); navigating through uncertainty and distrust (lacking tangible/perceptible benefits, unprepared for side effects, isolation in decision-making); alleviating treatment burdens (establishing and mastering routines, counteracting side effects, preparing for the unexpected); gaining and seeking confidence (clarity with knowledge, reassurance through collective experiences, focusing on the future outlook); recalibrating to a new normal posttransplant (adjusting to ongoing dependence on medications, in both states of illness and health, unfulfilled expectations); and preserving graft survival (maintaining the ability to participate in life, avoiding rejection, enacting a social responsibility of giving back). Transplant recipients take medications to preserve graft function, but dependence on medications jeopardizes their sense of normality. Interventions supporting the adaptation to medicine-taking and addressing treatment burdens may improve patient satisfaction and capacities to take medications for improved outcomes.
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http://dx.doi.org/10.1111/ajt.16613DOI Listing
April 2021

Equity in national policies for Australians with kidney disease.

Aust N Z J Public Health 2021 Apr 5. Epub 2021 Apr 5.

Centre for Kidney Research, The Children's Hospital at Westmead, New South Wales.

Objective: To describe how the Australian Government Department of Health policies address equity in the management of chronic kidney disease (CKD).

Methods: We searched the websites of the Australian Government Department of Health, Kidney Health Australia, Australian Indigenous HealthInfoNet and the National Rural Health Alliance for policies using the search terms: kidney, renal and chronic.

Results: We included 24 policies that addressed groups of people that experience health inequities: 23 addressed Aboriginal and Torres Strait Islander peoples, 18 rural/remote communities, 12 low socioeconomic status groups, six culturally and linguistically diverse communities and four addressed gender disparities. The scope of the policies ranged from broad national frameworks to subsidised access to health services and medicines. Only two policies explicitly addressed equity for patients with CKD.

Conclusion: CKD outcomes are highly variable across population groups yet Australian Government policies that address access to and the experience of care are limited in both number and their attention to equity issues. Implications for public health: In Australia, some groups of people with CKD have a substantially higher risk of mortality and morbidity than the general CKD population. We advocate for the development and implementation of policies to attain equity for people with CKD.
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http://dx.doi.org/10.1111/1753-6405.13096DOI Listing
April 2021

Malignancies after Kidney Transplantation.

Clin J Am Soc Nephrol 2021 Mar 29. Epub 2021 Mar 29.

Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia

Cancer is an important outcome after kidney transplantation because it is the second leading cause of death in most Western countries. The excess risk of cancer after transplantation is approximately two to three times higher than the age- and sex-matched general population, driven largely by viral- and immune-related cancers. Once cancer develops, outcomes are generally poor, particularly for those with melanoma, renal cell carcinoma, and post-transplant lymphoproliferative disease. More importantly, effective screening and treatment strategies are limited in this high-risk population. In this review, we begin with a patient's journey that maps the experience of living with a kidney transplant and understand the patient's knowledge, education, and experience of cancer in the context of transplantation. The epidemiology and burden of cancer in recipients of kidney transplants, along with the up-to-date screening and treatment strategies, are discussed. We also focus on the current understanding of optimal care for recipients of kidney transplants who are living with cancer from the patients' perspectives.
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http://dx.doi.org/10.2215/CJN.14570920DOI Listing
March 2021

Impact of deceased donor with acute kidney injury on subsequent kidney transplant outcomes-an ANZDATA registry analysis.

PLoS One 2021 25;16(3):e0249000. Epub 2021 Mar 25.

Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia.

Background: The need for kidney transplantation drives efforts to expand organ donation. The decision to accept organs from donors with acute kidney injury (AKI) can result in a clinical dilemma in the context of conflicting reports from published literature.

Material And Methods: This observational study included all deceased donor kidney transplants performed in Australia and New Zealand between 1997 and 2017. The association of donor-AKI, defined according to KDIGO criteria, with all-cause graft failure was evaluated by multivariable Cox regression. Secondary outcomes included death-censored graft failure, death, delayed graft function (DGF) and acute rejection.

Results: The study included 10,101 recipients of kidneys from 5,774 deceased donors, of whom 1182 (12%) recipients received kidneys from 662 (11%) donors with AKI. There were 3,259 (32%) all-cause graft failures, which included 1,509 deaths with functioning graft. After adjustment for donor, recipient and transplant characteristics, donor AKI was not associated with all-cause graft failure (adjusted hazard ratio [HR] 1.11, 95% CI 0.99-1.26), death-censored graft failure (HR 1.09, 95% CI 0.92-1.28), death (HR 1.15, 95% CI 0.98-1.35) or graft failure when death was evaluated as a competing event (sub-distribution hazard ratio [sHR] 1.07, 95% CI 0.91-1.26). Donor AKI was not associated with acute rejection but was associated with DGF (adjusted odds ratio [OR] 2.27, 95% CI 1.92-2.68).

Conclusion: Donor AKI stage was not associated with any kidney transplant outcome, except DGF. Use of kidneys with AKI for transplantation appears to be justified.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0249000PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7993825PMC
March 2021

Factors Influencing Long-Term Patient and Allograft Outcomes in Elderly Kidney Transplant Recipients.

Kidney Int Rep 2021 Mar 13;6(3):727-736. Epub 2020 Dec 13.

Department of Renal Medicine, Westmead Hospital, Sydney, Australia.

Introduction: Individuals aged ≥65 years are increasingly prevalent on the waitlist for kidney transplantation, yet evidence on recipient and donor factors that define optimal outcomes in elderly patients after kidney transplantation is scarce.

Methods: We used multivariable Cox regression modeling to determine the factors associated with all-cause death, death with a functioning graft, and overall and death-censored graft survival, using data from the Australia and New Zealand Dialysis and Transplant (ANZDATA) registry.

Results: A total of 802 kidney transplant recipients aged ≥65 years underwent their first transplantation between June 2006 and December 2016. Median age at transplantation was 68 years (interquartile range = 66-69 years). The 1-year and 5-year overall patient and graft survivals (95% confidence interval [CI]) were 95.1 (93.5-96.7) and 79.0 (75.1-82.9), and 92.9 (91.1-94.7) and 75.4 (71.3-79.5), respectively. Factors associated with higher risks of all-cause death included prevalent coronary artery disease (adjusted hazard ratio [95% confidence interval] = 1.47 [1.03-2.11]), cerebrovascular disease (1.99 [1.26-3.16]), increasing graft ischemic time (1.06 per hour [1.03-1.09]), donor age (1.02 per year [1.01-1.03]), delayed graft function (1.64 [1.13-2.39]), and peritoneal dialysis pretransplantation (1.71 [1.17-2.51]).

Conclusion: Prevalent vascular disease and peritoneal dialysis as a pretransplantation dialysis modality are risk factors associated with poorer outcomes in transplant recipients aged ≥65 years. Careful selection and evaluation of potential candidates may improve graft and patient outcomes in older patients.
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http://dx.doi.org/10.1016/j.ekir.2020.11.035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7938063PMC
March 2021

Survival and transplant outcomes among young children requiring kidney replacement therapy.

Pediatr Nephrol 2021 Mar 1. Epub 2021 Mar 1.

School of Medicine, University of Western Australia, Perth, WA, Australia.

Background: Young children starting kidney replacement therapy (KRT) suffer high disease burden with unique impacts on growth and development, timing of transplantation and long-term survival. Contemporary long-term outcome data and how these relate to patient characteristics are necessary for shared decision-making with families, to identify modifiable risk factors and inform future research.

Methods: We examined outcomes of all children ≤ 5 years enrolled in the Australia and New Zealand Dialysis and Transplant Registry, commencing KRT 1980-2017. Primary outcomes were patient and graft survival. Final height attained was also examined. We used generalized additive modelling to investigate the relationship between age and graft loss over time post-transplant.

Results: In total, 388 children were included, of whom 322 (83%) received a kidney transplant. Cumulative 1-, 5- and 10-year patient survival probabilities were 93%, 86% and 83%, respectively. Death censored graft survival at 1, 5 and 10 years was 93%, 87% and 77%, respectively. Most children were at least 10 kg at transplantation (n = 302; 96%). A non-linear relationship between age at transplantation and graft loss was observed, dependent on time post-transplant, with increased risk of graft loss among youngest recipients both initially following transplantation and subsequently during adolescence. Graft and patient survival have improved in recent era.

Conclusions: Young children commencing KRT have good long-term survival and graft outcomes. Early graft loss is no reason to postpone transplantation beyond 10 kg, and among even the youngest recipients, late graft loss risk in adolescence remains one of the greatest barriers to improving long-term outcomes.
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http://dx.doi.org/10.1007/s00467-021-04945-9DOI Listing
March 2021

Dietary intake in adults on hemodialysis compared with guideline recommendations.

J Nephrol 2021 Feb 16. Epub 2021 Feb 16.

Faculty of Medicine and Health, Sydney School of Public Health, University of Sydney, Sydney, Australia.

Background: Clinical practice guidelines of dietary management are designed to promote a balanced diet and maintain health in patients undergoing haemodialysis but they may not reflect patients' preferences. We aimed to investigate the consistency between the dietary intake of patients on maintenance haemodialysis and guideline recommendations.

Methods: Cross-sectional analysis of the DIET-HD study, which included 6,906 adults undergoing haemodialysis in 10 European countries. Dietary intake was determined using the Global Allergy and Asthma European Network (GALEN) Food Frequency Questionnaire (FFQ), and compared with the European Best Practice Guidelines. Consistency with guidelines was defined as achieving the minimum daily recommended intake for energy (≥ 30 kcal/kg) and protein (≥ 1.1 g/kg), and not exceeding the maximum recommended daily intake for phosphate (≤ 1000 mg), potassium (≤ 2730 mg), sodium (≤ 2300 mg) and calcium (≤ 800 mg).

Results: Overall, patients' dietary intakes of phosphate and potassium were infrequently consistent with guidelines (consistent in 25% and 25% of patients, respectively). Almost half of the patients reported that energy (45%) and calcium intake (53%) was consistent with the guidelines, while the recommended intake of sodium and protein was consistent in 85% and 67% of patients, respectively. Results were similar across all participating countries. Intake was consistent with all six guideline recommendations in only 1% of patients.

Conclusion: Patients on maintenance haemodialysis usually have a dietary intake which is inconsistent with current recommendations, especially for phosphate and potassium.
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http://dx.doi.org/10.1007/s40620-020-00962-3DOI Listing
February 2021

Protection From the Second Warm Ischemic Injury in Kidney Transplantation Using an Ex Vivo Porcine Model and Thermally Insulating Jackets.

Transplant Proc 2021 Mar 11;53(2):750-754. Epub 2021 Feb 11.

Sydney Medical School, University of Sydney, Sydney, Australia; Department of Surgery, Westmead Hospital, Westmead, Australia.

Background: Kidney transplantation is the optimum treatment for kidney failure in carefully selected patients. Technical surgical complications and second warm ischemic time (SWIT) increase the risk of delayed graft function (DGF) and subsequent short- and long-term graft outcomes including the need for post-transplant dialysis and graft failure. Intraoperative organ thermal regulation could reduce SWIT, minimizing surgical complications due to time pressure, and limiting graft ischemia-reperfusion injury.

Methods: A novel ischemic-injury thermal protection jacket (iiPJ) was designed and fabricated in silicone composite and polyurethane (PU) elastomer prototypes. Both were compared with no thermal insulation as controls. Time to reach ischemic threshold (15°C) and thermal energy transfer were compared. A water bath model was used to examine the thermal protective properties of porcine kidneys, as a feasibility study prior to in vivo translation.

Results: In both iterations of the iiPJ, the time taken to reach the warm ischemia threshold was 35.2 ± 1.4 minutes (silicone) and 38.4 ± 3.1 minutes (PU), compared with 17.2 ± 1.5 minutes for controls (n = 5, P < .001 for both comparisons). Thermal energy transfer was also found to be significantly less for both iiPJ variants compared with controls. There was no significant difference between the thermal performance of the 2 iiPJ variants.

Conclusion: Protection from SWIT by using a protective insulation jacket is feasible. With clinical translation, this novel strategy could facilitate more optimal surgical performance and reduce transplanted organ ischemia-reperfusion injury, in particular the SWIT, potentially affecting delayed graft function and long-term outcomes.
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http://dx.doi.org/10.1016/j.transproceed.2021.01.037DOI Listing
March 2021

Impact of Pretransplant and New-Onset Diabetes After Transplantation on the Risk of Major Adverse Cardiovascular Events in Kidney Transplant Recipients: a Population-Based Cohort Study.

Transplantation 2021 Feb 4. Epub 2021 Feb 4.

Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Australia Medical School, University of Western Australia, Perth, Australia Division of Nephrology, Department of Medicine, University Health Network-Toronto General Hospital, Toronto, Canada The University of Toronto, Toronto, Canada Division of Nephrology, Department of Medicine, University of Ottawa, Ontario, Canada Clinical Epidemiology Program, Ottawa Health Research Institute, Ontario, Canada Department of Medicine, University of Toronto, Toronto, Ontario, Canada Division of Endocrinology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada ICES, London, Ontario, Canada Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada Princess Alexandra Hospital, Metro South and Ipswich Nephrology and Transplant Services, Queensland, Australia University of Queensland, Queensland, Australia Translational Research Institute, Brisbane, Australia School of Biomedical Sciences, University of Western Australia, Perth, Australia; University of Sydney, Sydney, Australia Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia Department of Renal Medicine and National Pancreas Transplant Unit, Westmead Hospital, Sydney, Australia.

Background: Pretransplant diabetes and new onset diabetes after transplant (NODAT) are known risk factors for vascular events after kidney transplantation but the incidence and magnitude of the risk of major adverse cardiovascular events (MACE) and cardiac deaths remains uncertain in recent era.

Methods: A population cohort study of kidney transplant recipients identified using data from linked administrative healthcare databases from Ontario, Canada. The incidence rates of MACE (expressed as events with 95% confidence interval (95%CI) per 1000-person-years were reported according to diabetes status of pretransplant diabetes, NODAT or no diabetes. Extended Cox regression model was used to examine the association between diabetes status, MACE and cardiac death.

Results: Of 5248 recipients, 1973 (38%) had pretransplant diabetes and 799 (15%) developed NODAT with a median follow-up of 5.5 years. The incidence rates (95%CI) of MACE for recipients with pretransplant diabetes, NODAT and no diabetes between 1-3 years posttransplant were 38.1 (32.1-45.3), 12.6 (6.3-25.2) and 11.8 (9.2-15.0) per 1000-person-years, respectively. Compared to recipients with pretransplant diabetes, recipients with NODAT experienced a lower risk of MACE (adjusted hazard ratio [HR]0.59, 95%CI 0.47-0.74]), but not cardiac death [0.97(0.61-1.55)]. The rate of MACE and cardiac death was lowest in patients without diabetes.

Conclusions: Patients with pretransplant diabetes incur the greatest rate of MACE and cardiac deaths after transplantation. Having NODAT also bear high burden of vascular events compared to those without diabetes, but the magnitude of the increased rate remains lower than recipients with pretransplant diabetes.
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http://dx.doi.org/10.1097/TP.0000000000003639DOI Listing
February 2021

Trash or Treasure: Rescuing Discard Kidneys.

Transplantation 2021 Feb 1. Epub 2021 Feb 1.

School of Mathematics and Statistics, The University of Sydney, NSW, Australia Sydney School of Public Health, University of Sydney, NSW, Australia Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia.

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http://dx.doi.org/10.1097/TP.0000000000003663DOI Listing
February 2021

Prognostic Value of Abdominal Aortic Calcification: A Systematic Review and Meta-Analysis of Observational Studies.

J Am Heart Assoc 2021 01 13;10(2):e017205. Epub 2021 Jan 13.

Centre for Kidney Research School of Public Health Faculty of Medicine and Health Children's Hospital at WestmeadThe University of Sydney New South Wales Australia.

Background The prognostic importance of abdominal aortic calcification (AAC) viewed on noninvasive imaging modalities remains uncertain. Methods and Results We searched electronic databases (MEDLINE and Embase) until March 2018. Multiple reviewers identified prospective studies reporting AAC and incident cardiovascular events or all-cause mortality. Two independent reviewers assessed eligibility and risk of bias and extracted data. Summary risk ratios (RRs) were estimated using random-effects models comparing the higher AAC groups combined (any or more advanced AAC) to the lowest reported AAC group. We identified 52 studies (46 cohorts, 36 092 participants); only studies of patients with chronic kidney disease (57%) and the general older-elderly (median, 68 years; range, 60-80 years) populations (26%) had sufficient data to meta-analyze. People with any or more advanced AAC had higher risk of cardiovascular events (RR, 1.83; 95% CI, 1.40-2.39), fatal cardiovascular events (RR, 1.85; 95% CI, 1.44-2.39), and all-cause mortality (RR, 1.98; 95% CI, 1.55-2.53). Patients with chronic kidney disease with any or more advanced AAC had a higher risk of cardiovascular events (RR, 3.47; 95% CI, 2.21-5.45), fatal cardiovascular events (RR, 3.68; 95% CI, 2.32-5.84), and all-cause mortality (RR, 2.40; 95% CI, 1.95-2.97). Conclusions Higher-risk populations, such as the elderly and those with chronic kidney disease with AAC have substantially greater risk of future cardiovascular events and poorer prognosis. Providing information on AAC may help clinicians understand and manage patients' cardiovascular risk better.
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http://dx.doi.org/10.1161/JAHA.120.017205DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7955302PMC
January 2021

Sex matters: COVID-19 in kidney transplantation.

Kidney Int 2021 03 5;99(3):555-558. Epub 2021 Jan 5.

Canadian Donation and Transplantation Research Program, Edmonton, Alberta, Canada; Division of Nephrology, Department of Medicine, McGill University, Montreal, Quebec, Canada; Centre for Outcomes Research, Research Institute of McGill University Health Centre, Montreal, Quebec, Canada. Electronic address:

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http://dx.doi.org/10.1016/j.kint.2020.12.020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7783460PMC
March 2021

Health-Related Quality of Life in People Across the Spectrum of CKD.

Kidney Int Rep 2020 Dec 3;5(12):2264-2274. Epub 2020 Oct 3.

College of Medicine and Public Health, Flinders University, Adelaide, Australia.

Introduction: People with chronic kidney disease (CKD) experience reduced quality of life (QoL) because of the high symptom and treatment burden. Limited data exist on the factors associated with overall and domain-specific QoL across all CKD stages.

Methods: Using data from a prospective, multinational study (Australia, New Zealand, Canada, and Spain) in 1696 participants with CKD, we measured overall and domain-specific QoL (pain, self-care, activity, mobility, anxiety/depression) using the EuroQoL, 5 dimension, 3 level. Multivariable linear regression and logistic modeling were used to determine factors associated with overall and domain-specific QoL.

Results: QoL for patients with CKD stages 3 to 5 (n = 787; mean, 0.81; SD, 0.20) was higher than in patients on dialysis (n = 415; mean, 0.76; SD, 0.24) but lower than in kidney transplant recipients (n = 494; mean, 0.84; SD, 0.21). Factors associated with reduced overall QoL (β [95% confidence intervals]) included being on dialysis (compared with CKD stages 3-5: -0.06 [-0.08 to -0.03]), female sex (-0.03 [-0.05 to -0.006]), lower educational attainment (- 0.04 [-0.06 to -0.02), lacking a partner (-0.04 [-0.06 to -0.02]), having diabetes (-0.05 [-0.07 to -0.02]), history of stroke (-0.09 [-0.13 to -0.05]), cardiovascular disease (-0.06 [-0.08 to -0.03]), and cancer (-0.03 [-0.06 to -0.009]). Pain (43%) and anxiety/depression (30%) were the most commonly affected domains, with dialysis patients reporting decrements in all 5 domains. Predictors for domain-specific QoL included being on dialysis, presence of comorbidities, lower education, female sex, and lack of a partner.

Conclusions: Being on dialysis, women with CKD, those with multiple comorbidities, lack of a partner, and lower educational attainment were associated with lower QoL across all stages of CKD.
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http://dx.doi.org/10.1016/j.ekir.2020.09.028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7710842PMC
December 2020

Prevalence, incidence and risk factors of diabetes in Australian adults aged ≥45 years: A cohort study using linked routinely-collected data.

J Clin Transl Endocrinol 2020 Dec 10;22:100240. Epub 2020 Nov 10.

The George Institute for Global Health, UNSW, Sydney, NSW, Australia.

Aims: To use linked routinely-collected health data to estimate diabetes prevalence and incidence in an Australian cohort of adults aged ≥45 years, and examine risk factors associated with incident disease.

Research Design And Methods: The EXamining ouTcomEs in chroNic Disease in the 45 and Up Study (EXTEND45) Study is a linked data study that combines baseline questionnaire responses from the population-based (2006-2009,  = 267,153) with multiple routinely-collected health databases up to December 2014. Among participants with ≥1 linked result for any laboratory test, diabetes status was determined from multiple data sources according to standard biochemical criteria, use of glucose-lowering medication or self-report, and the prevalence and incidence rate calculated. Independent risk factors of incident diabetes were examined using multivariable Cox regression.

Results: Among 152,169 participants with ≥1 linked laboratory result in the EXTEND45 database (mean age 63.0 years; 54.9% female), diabetes prevalence was 10.8% (95% confidence interval [CI] 10.6%-10.9%). Incident disease in those without diabetes at baseline ( = 135,810; mean age 62.5 years; 56.1% female) was 10.0 per 1,000 person-years (95% CI 9.8-10.2). In all age groups, diabetes incidence was lower in women compared to men, an association that persisted in the fully adjusted analyses. Other independent risk factors of diabetes were older age, being born outside of Australia (with the highest rate of 19.2 per 1,000 person-years observed in people born in South and Central Asia), lower education status, lower annual household income, residence in a major city, family history of diabetes, personal history of cardiovascular disease or hypertension, higher body mass index, smoking and long sleeping hours.

Conclusions: Our study represents an efficient approach to assessing diabetes frequency and its risk factors in the community. The infrastructure provided by the EXTEND45 Study will be useful for diabetes surveillance and examining other important clinical and epidemiological questions.
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http://dx.doi.org/10.1016/j.jcte.2020.100240DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7691170PMC
December 2020

KDIGO Controversies Conference on onco-nephrology: kidney disease in hematological malignancies and the burden of cancer after kidney transplantation.

Kidney Int 2020 12;98(6):1407-1418

Department of Internal Medicine and Therapeutics, University of Pavia and Division of Translational Oncology, IRCCS Istituti Clinici Scientifici Maugeri, Pavia, Italy. Electronic address:

The bidirectional relationship between cancer and chronic kidney disease (CKD) is complex. Patients with cancer, particularly those with hematological malignancies such as multiple myeloma and lymphoma, are at increased risk of developing acute kidney injury and CKD. On the other hand, emerging evidence from large observational registry analyses have consistently shown that cancer risk is increased by at least 2- to 3-fold in kidney transplant recipients, and the observed increased risk occurs not only in those who have received kidney transplants but also in those on dialysis and with mild- to moderate-stage CKD. The interactions between cancer and CKD have raised major therapeutic and clinical challenges in the management of these patients. Given the magnitude of the problem and uncertainties, and current controversies within the existing evidence, Kidney Disease: Improving Global Outcomes (KDIGO) assembled a global panel of multidisciplinary clinical and scientific expertise for a controversies conference on onco-nephrology to identify key management issues in nephrology relevant to patients with malignancy. This report covers the discussed controversies in kidney disease in hematological malignancies, as well as cancer after kidney transplantation. An overview of future research priorities is also discussed.
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http://dx.doi.org/10.1016/j.kint.2020.07.012DOI Listing
December 2020

Epidemiology of kidney disease: consolidating and integrating the evidence to improve kidney care from early childhood to adulthood.

Kidney Int 2020 12;98(6):1378-1381

Department of Transplant Medicine, Royal Adelaide Hospital, Adelaide, South Australia, Australia.

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http://dx.doi.org/10.1016/j.kint.2020.09.020DOI Listing
December 2020

Patient needs and priorities for patient navigator programmes in chronic kidney disease: a workshop report.

BMJ Open 2020 11 5;10(11):e040617. Epub 2020 Nov 5.

Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia.

Background And Objective: Patients with early chronic kidney disease (CKD) face challenges in accessing healthcare, including delays in diagnosis, fragmented speciality care and lack of tailored education and psychosocial support. Patient navigator programmes have the potential to improve the process of care and outcomes. The objective of this study is to describe the experiences of patients on communication, access of care and self-management and their perspectives on patient navigator programmes in early CKD.

Design, Setting And Participants: We convened a workshop in Australia with 19 patients with CKD (all stages including CKD Stage 1 to 5 not on dialysis, 5D (dialysis), and 5T (transplant)) and five caregivers. All of them were over 18 years and English-speaking. Transcripts from the workshop were analysed thematically.

Results: Four themes that captured discussions were: lost in the ambiguity of symptoms and management, battling roadblocks while accessing care, emotionally isolated after diagnosis and re-establishing lifestyle and forward planning. Five themes that focussed on patient navigator programmes were: trust and credibility, respecting patient choices and readiness to accept the programme, using accessible language to promote the programme, offering multiple ways to engage and communicate and maintaining confidentiality and privacy. Of the 17 features identified as important for a patient navigator programme, the top five were delivery of education, psychosocial support, lifestyle modification, communication and decision-making support and facilitating care.

Conclusion: Patient navigator services can address gaps in services around health literacy, communication, psychosocial support and coordination across multiple healthcare settings. In comparison to the existing navigator programmes, and other services that are aimed at addressing these gaps, credible, accessible and flexible patient navigator programmes for patients with early CKD, that support education, decision-making, access to care and self-management designed in partnership with patients, may be more acceptable to patients.
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http://dx.doi.org/10.1136/bmjopen-2020-040617DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7646342PMC
November 2020

Integrative Analysis of Prognostic Biomarkers for Acute Rejection in Kidney Transplant Recipients.

Transplantation 2021 Jun;105(6):1225-1237

School of Mathematics and Statistics, University of Sydney, Sydney, NSW, Australia.

Background: Noninvasive biomarkers may predict adverse events such as acute rejection after kidney transplantation and may be preferable to existing methods because of superior accuracy and convenience. It is uncertain how these biomarkers, often derived from a single study, perform across different cohorts of recipients.

Methods: Using a cross-validation framework that evaluates the performance of biomarkers, the aim of this study was to devise an integrated gene signature set that predicts acute rejection in kidney transplant recipients. Inclusion criteria were publicly available datasets of gene signatures that reported acute rejection episodes after kidney transplantation. We tested the predictive probability for acute rejection using gene signatures within individual datasets and validated the set using other datasets. Eight eligible studies of 1454 participants, with a total of 512 acute rejections episodes were included.

Results: All sets of gene signatures had good positive and negative predictive values (79%-96%) for acute rejection within their own cohorts, but the predictability reduced to <50% when tested in other independent datasets. By integrating signature sets with high specificity scores across all studies, a set of 150 genes (included CXCL6, CXCL11, OLFM4, and PSG9) which are known to be associated with immune responses, had reasonable predictive values (varied between 69% and 90%).

Conclusions: A set of gene signatures for acute rejection derived from a specific cohort of kidney transplant recipients do not appear to provide adequate prediction in an independent cohort of transplant recipients. However, the integration of gene signature sets with high specificity scores may improve the prediction performance of these markers.
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http://dx.doi.org/10.1097/TP.0000000000003516DOI Listing
June 2021

Socioeconomic Status During Childhood and Academic Achievement in Secondary School.

Acad Pediatr 2020 Oct 27. Epub 2020 Oct 27.

Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney (A van Zwieten, A Teixeira-Pinto, and G Wong), Sydney, NSW, Australia; Centre for Kidney Research, The Children's Hospital at Westmead (A van Zwieten, A Teixeira-Pinto, and G Wong), Westmead, NSW, Australia; Department of Renal Medicine, Westmead Hospital (G Wong), Westmead, NSW, Australia.

Objective: Secondary education has lifelong implications for well-being. We evaluated associations between the timing and duration of low socioeconomic status (SES) during childhood and academic achievement in secondary school.

Methods: Cohort design. The structured modeling approach was used to evaluate life-course models for associations between the duration and timing of low SES (across ages 4-5, 6-7, 8-9, 10-11 years) and Grade 7 (median age 12.5 years) reading and numeracy achievement. Linear regressions were fitted for 4 critical period models (each including low SES at 1 age), 1 sensitive period model (including low SES at all ages), and 2 strict accumulation models (including low SES duration in linear/categorical form).

Results: Of 3734 children, 1718 (46.1%), 1749 (48.6%), 1797 (49.3%), and 1779 (49.8%) experienced low SES at 4 to 5, 6 to 7, 8 to 9, and 10 to 11 years, respectively. For reading, the sensitive period model fitted best. Reading z-score coefficients for low SES (reference: high SES) at 4 to 5, 6 to 7, 8 to 9, and 10 to 11 years were: -0.20, -0.18, -0.02, and -0.22. For numeracy, the categorical strict accumulation model, with SES-by-sex interaction, fitted best. Numeracy z-score coefficients for 1, 2, 3, and 4 periods of low SES (reference: 0 periods) were: -0.38, -0.42, -0.54, and -0.77 for boys, and -0.23, -0.34, -0.42, and -0.54 for girls.

Conclusions: Low SES at all ages studied except 8 to 9 years has cumulative associations with poorer Grade 7 reading. Longer duration of low SES from 4 to 11 years is associated with poorer Grade 7 numeracy, with stronger associations for boys than girls. Academic interventions should be targeted toward children with persistently low SES.
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http://dx.doi.org/10.1016/j.acap.2020.10.013DOI Listing
October 2020

KDIGO Controversies Conference on onco-nephrology: understanding kidney impairment and solid-organ malignancies, and managing kidney cancer.

Kidney Int 2020 11;98(5):1108-1119

Department of Nephrology, Dialysis, and Internal Medicine, Medical University of Warsaw, Poland. Electronic address:

The association between kidney disease and cancer is multifaceted and complex. Persons with chronic kidney disease (CKD) have an increased incidence of cancer, and both cancer and cancer treatments can cause impaired kidney function. Renal issues in the setting of malignancy can worsen patient outcomes and diminish the adequacy of anticancer treatments. In addition, the oncology treatment landscape is changing rapidly, and data on tolerability of novel therapies in patients with CKD are often lacking. Caring for oncology patients has become more specialized and interdisciplinary, currently requiring collaboration among specialists in nephrology, medical oncology, critical care, clinical pharmacology/pharmacy, and palliative care, in addition to surgeons and urologists. To identify key management issues in nephrology relevant to patients with malignancy, KDIGO (Kidney Disease: Improving Global Outcomes) assembled a global panel of multidisciplinary clinical and scientific expertise for a controversies conference on onco-nephrology in December 2018. This report covers issues related to kidney impairment and solid organ malignancies as well as management and treatment of kidney cancer. Knowledge gaps, areas of controversy, and research priorities are described.
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http://dx.doi.org/10.1016/j.kint.2020.06.046DOI Listing
November 2020

Kidney International 60th anniversary edition: transplantation-the chosen 5.

Kidney Int 2020 11;98(5):1064-1066

Renal Unit, Royal Adelaide Hospital, South Australia, Australia. Electronic address:

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http://dx.doi.org/10.1016/j.kint.2020.09.005DOI Listing
November 2020

Discrete Choice Experiments to Elicit Patient Preferences for Decision Making in Transplantation.

Transplantation 2021 May;105(5):960-967

Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.

Providing care for transplant recipients is challenging given the need to maintain optimal graft function and survival while managing the debilitating side effects and complications associated with immunosuppression including infection, cancer, new-onset diabetes mellitus, and cardiovascular disease. Given the complexity of treatment options and the uncertainty about long-term benefits and harms of treatment, understanding patient preferences and values are key to ensuring that clinical decisions take into consideration patient priorities to support shared decision making and self-management. Choice experiments are increasingly used to quantify patient and community preferences, including in the field of transplantation. Discrete choice experiments (DCEs) are a well-established, validated methodology used to elicit preferences for decision making in health and other settings. In transplantation, for example, DCEs have been used to elicit patient preferences for outcomes following kidney transplantation, to identify community preferences factors for organ allocation and in establishing core outcomes. This article provides an overview of the concepts and methods used in the design of DCEs and how patients' preferences can be applied in shared decision making in transplantation.
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http://dx.doi.org/10.1097/TP.0000000000003500DOI Listing
May 2021