Transplant Waiting List Status of Patients With Diabetic Kidney Disease

ERA 60^th Congress

As identified by the 24th Annual Renal Registry Report, the most common primary renal disease in patients initiating renal replacement  therapy (RRT) is diabetes. The prevalence of diabetes in patients with kidney failure was 30.5% at the end of 2020, an increase from 27.0% in 2015.

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Recommendations from the Renal Association and British Transplantation Society suggest that patients with a body mass index (BMI) >30 kg/m² are at heightened risk of complications and should be discouraged from kidney transplantation. The transplant center at St. James’s University Hospital, at the Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom, accepts candidates with a BMI up to 35 kg/m² for kidney transplant alone transplantation.

However, according to Maria Angela Gauci and colleagues at the center, there is still a significant proportion of patients suspended from the deceased donor transplant waiting list due to an unacceptably raised BMI. The researchers conducted an analysis to examine barriers to transplantation in patients with diabetic kidney disease at the St. James’s University Hospital transplant center. Results were reported at the ERA 60th Congress in a presentation titled The Barriers to Transplantation in Our Diabetic Hemodialysis Population at the Leeds Teaching Hospitals NHS Trust.

Data were collected using clinic letters or records uploaded to the Patient pathway Managed and the BHLY (Bradford, Hull, Leeds, and York) Renal Patient System. The study included patients with diabetic kidney disease who were receiving either home or in-center hemodialysis. The study was designed to examine the demographics of the diabetic hemodialysis population at the center, and to determine the reasons for suspension from the renal transplant waiting list, with a focus on obesity.

Of the 631 patients receiving hemodialysis from the Leeds renal services, 248 had diabetic kidney disease. Of those 248 patients, 66% were male and the mean age was 60 years. Just over 50% were White, and 30% were South Asian.

At the end of December 2022, nearly 20% (n=119) of all hemodialysis patients were active on the national deceased transplant waiting list. However, only 14% (n=35) of the subpopulation of patients with diabetic kidney disease on hemodialysis were active, 13% (n=31) were under assessment, and 14% (n=35) were declined and/or disengaged from assessment for transplantation, The remaining patients were either temporarily or permanently suspended. Ten percent (n=24) of all diabetic hemodialysis patients were suspended due to a BMI >35 kg/m².

“Our audit reveals that only 14% of the hemodialysis diabetic population is presently active on the deceased transplant waiting list,” the authors said. “This remains suboptimal, as renal or simultaneous pancreas kidney transplantation is the gold standard for diabetes-induced end-stage kidney disease (ESKD). Obesity (BMI >35) was a reason for temporary suspension in 10% of our hemodialysis diabetic population. Therefore, we need to target this comorbidity in a timely manner in order to optimize patients for transplantation.

“NICE [National Institute for Health and Care Excellence] recommend pharmacological weight-lowering therapy for people who have failed to achieve a healthy BMI following conservative methods. Such medical therapy (eg, liraglutide) is still yet to be evaluated in depth in the ESKD-hemodialysis obese population. Only one patient in our cohort was being treated with liraglutide, while the rest [were] either on insulin, linagliptin, gliclazide, or nonpharmacological dietary modification.

“The authors of this study encourage the inclusion of CKD 5 patients on liraglutide, before they are started on hemodialysis, in order to pave their way to transplantation before it is too late.”

Source: Gauci MA, Ahmed M, Gullapudi VRL, Wright M. The barriers to transplantation in our diabetic hemodialysis population at the Leeds Teaching Hospitals NHS Trust. Presentation #6884. Abstract of a presentation at the European Renal Association 60^th Congress; June 15-18, 2023; Milan, Italy.