Analysis looks at long-term risks of living kidney donation

1. Analysis looks at long-term risks of living kidney donation
Abstract: http://annals.org/aim/article/doi/10.7326/M17-1235
Editorial: http://annals.org/aim/article/doi/10.7326/M17-3249
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Living kidney donors are not at increased risk for some health outcomes previously of concern, but do seem at risk for worse blood pressure and kidney function than nondonors. In addition, female donors seem to be at increased risk for preeclampsia. The findings of a systematic review and meta-analysis are published in Annals of Internal Medicine.

A team lead by researchers from the University of Cambridge, England, reviewed 52 published studies comprising more than 100,000 living kidney donors and more than 110,000 nondonors to assess the mid- and long-term health risks associated with living kidney donation in adults.

The data showed that kidney donors had higher diastolic blood pressure, poorer renal function, and higher risk for ESRD than nondonors. Female donors had an almost two-fold higher risk than nondonors for pregnancy-related complications, such as preeclampsia.

There was no evidence that living kidney donors had higher risk for mortality, cardiovascular disease, or type 2 diabetes, or reduced quality of life. Lead author, Emanuele Di Angelantonio, MD, Director of the NIHR Blood and Transplant Unit (BTRU) in Donor Health and Genomics suggested that the findings may be used to inform prospective donors of the risks associated with kidney donation.

The authors of an editorial from the University of Pennsylvania write that despite 6 decades of living kidney donation, large and high-quality studies of ESRD and other relevant outcomes after donation have been completed only in the past decade. While the systematic review and meta-analysis provide some important answers, the field is still a long way from offering precise risk estimates to prospective donors.

The study was funded by the NIHR Blood and Transplant Research Unit with the NIHR Cambridge Biomedical Research Centre funding part of the study.

Media contacts: For an embargoed PDF, please contact Angela Collom. The lead author, Emanuele Di Angelantonio, MD, can be contacted directly at ed303@medschl.cam.ac.uk.

2. Fentanyl use associated with an unusual cluster of amnesia cases
Abstract: http://annals.org/aim/article/doi/10.7326/L17-0575
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Fentanyl use has now been associated with an unusual amnestic syndrome that was first identified in 14 patients treated in Massachusetts between 2012 and 2016. Those patients, all of whom had a history of substance use, developed a syndrome that included acute, complete, and bilateral hippocampal lesions on magnetic resonance imaging (MRI). A report describing an additional case treated outside of the original Massachusetts cluster is published in Annals of Internal Medicine.

In May 2017, a 30-year-old man with a history of drug abuse was treated at a West Virginia hospital for persistent memory impairment. According to the man's family members, the patient had a history of heroin use, was recently discharged from a residential addiction treatment program, and had been abstinent from drugs for more than a month. However, after an apparent relapse, the man seemed to exhibit signs of acute and persistent memory impairment. His urine tests were negative for fentanyl, but revealed the presence of its metabolite norfentanyl. Blood testing also revealed evidence of cocaine use.

According to the researchers from West Virginia University School of Medicine, this case, coupled with another man who was previously treated at this hospital for a similar syndrome, forms the first cluster of the amnestic syndrome to be documented outside of Massachusetts. Given the apparent wider distribution of the syndrome, the researchers recommend that clinicians who encounter patients with substance use disorders and new-onset amnesia consistent with these cases should consider requesting diffusion-weighted magnetic resonance imaging of the head, neurologic consultation, and toxicology studies, including those that are specific for fentanyl, its metabolites, and its analogues.

Media contacts: For an embargoed PDF, please contact Angela Collom. For an interview with Marc Haut, PhD, ABPP, please contact Tara Scatterday at tdscatterday@hsc.wvu.edu or 304-293-0630.

3. Patients with sleep apnea achieve similar outcomes when receiving care from a sleep specialist or nonspecialist
Abstract: http://annals.org/aim/article/doi/10.7326/M17-2511
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Patients with obstructive sleep apnea (OSA) can achieve similar outcomes with care from a sleep specialist or a non-sleep specialist. The findings of a systematic review are published in Annals of Internal Medicine.

OSA is associated with excessive daytime sleepiness, decreased quality of life, myocardial infarction, heart failure, stroke, and cognitive decline. OSA treatments can improve daytime sleepiness and quality of life. As such, it is important that people with unexplained daytime somnolence be evaluated for OSA and receive adequate treatment. Until recently, OSA diagnosis and care models relied on sleep specialist physicians. Newer treatment models have been proposed that would reduce reliance on these specialists by including providers not specifically trained as sleep specialists, such as nurses or primary care physicians.

Researchers from the Minneapolis Veterans Affairs Health Care System Evidence-based Synthesis Program and the University of Minnesota, School of Medicine reviewed 12 published studies to evaluate the effectiveness and harms of care by non-sleep specialists versus sleep specialists for patients with suspected or diagnosed OSA. The researchers assessed the studies to determine patient-centered outcomes (mortality, access to care, quality of life, patient satisfaction, adherence, symptom scores, and adverse events) and other outcomes, including resource use, costs, time to initiation of treatment, and case finding. The data showed low-strength evidence that OSA management outcomes are similar whether provided by primary care physicians, sleep specialist nurses, or sleep specialist physicians. The evidence was insufficient to assess for access to care or adverse events.

The researchers suggest more research to confirm these findings in other settings and among providers with different levels of experience and training and to determine how such care models should be implemented.

Media contacts: For an embargoed PDF, please contact Angela Collom. For an interview with Timothy J. Wilt, MD, MPH, please contact Ralph Heussner at Ralph.Heussner@va.gov.

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