Progress in Transplantation

New-onset diabetes after transplantation (NODAT) has been associated with cardiovascular and thrombotic complications, acute rejection, and infection in transplant recipients. NODAT in kidney transplantation is well described; however, data are lacking in liver transplant recipients.

To evaluate the incidence of new-onset diabetes within 6 months postoperatively in adult liver transplant recipients.

Patients who underwent a liver transplantation at our institution between January 2004 and December 2005 were retrospectively evaluated. NODAT was defined according to the diagnostic criteria of the American Diabetes Association/World Health Organization, persistent hyperglycemia (serum glucose ≥200 mg/dL occurring 2 weeks after initial steroid induction and persisting for more than 2 weeks), or the need for hypoglycemic agents upon discharge.

Incidence of NODAT within 6 months after transplantation in patients with poor glycemic control within the first 2 weeks after transplantation, acute rejection episodes, infections, hospital readmissions, and cardiovascular and thrombotic events.

Forty-five patients were evaluated. Within the first 6 months after transplantation, NODAT developed in 11 (24%). Acute rejection, infection, hospital readmissions, cardiovascular events, and thrombotic events did not differ between the groups.

Elevated fasting levels of blood glucose during the first 2 weeks after liver transplantation may be associated with an increased incidence of NODAT and may have predictive value. More studies are needed to determine the effects of recognition and treatment of hyperglycemia in recent transplant recipients.

Kidney transplantation from living donors, compared with deceased donors, has improved health care outcomes for patients with end-stage renal disease; however, less than 40% of transplants come from living donors. Numerous barriers may impede the identification of, and transplantation from, living donors.

To develop and validate a survey to identify barriers that transplant candidates may encounter when seeking a living donor for kidney transplantation.

The survey was developed in 3 phases: item identification by using persons with a stake in the process to identify key components; survey refinement, including assessment of content and face validity; and assessment of test-retest reliability by using the kappa coefficient and percent agreement for each of the scaled response items.

The final survey contained 10 items with a Likert scale response and 5 open-ended questions. Expert nephrologists in the field confirmed face validity and content validity of the survey. The overall kappa coefficient for the scale was 0.76, reflecting excellent agreement, with an overall percent agreement of 88.7%.

We developed a survey to identify barriers that kidney transplant candidates may experience when seeking a living donor, which demonstrated content and face validity as well as reproducibility. This survey can by used by end-stage renal disease programs to identify barriers in candidates seeking a transplant. The results of the survey can be used to develop interventions to overcome such barriers with an ultimate goal of increasing rates of living kidney donation.

Immunosuppressive regimens increase kidney transplant patients' risk of contracting life-threatening influenza. However, little information exists about the prevalence and correlates of influenza vaccinations in this population.

To determine the prevalence and explore correlates of influenza vaccination in kidney transplant recipients.

This cross-sectional study used data from the Supporting Medication Adherence in Renal Transplantation study. The convenience sample consisted of 356 adult kidney transplant recipients (58.1% male; mean age, 52.9 [SD 13.53] years) recruited from 2 Swiss transplant outpatient clinics. Influenza vaccination status was assessed by self-report (yes/no).

Known correlates of vaccination in chronically ill patients (older age, cohabitation, higher education, higher socioeconomic status, financial stability, more comorbid diseases, nonsmoking status, and clinical site where care is received) were entered into a multiple logistic regression model.

Of the 356 patients, only 83 (23.3%) reported having been vaccinated against influenza in the previous year. Positive vaccination status was significantly related to older age (odds ratio, 1.04; 95% confidence interval, 1.02–1.06).

Despite national and international guidelines recommending influenza vaccination in kidney transplant recipients, the prevalence of influenza vaccination in this sample was low. This study's results suggest that transplant centers need to implement policies to maximize influenza vaccination of their patients.

Lung transplantation extends survival for some patients with advanced cystic fibrosis, but it is complicated, has many potential risks, and its outcomes are difficult to predict. No standards exist for informed decision making about transplantation.

To assess decision making from the perspective of caregivers of patients who faced the transplant decision before dying of cystic fibrosis or transplant complications.

Semistructured interviews with descriptive and qualitative content analysis.

Twenty-eight caregivers of patients with cystic fibrosis who received care at our center and died between 1996 and 2006.

Of 28 patients who considered lung transplantation, 19 (68%) received transplants, 6 (21%) died while waiting for transplant, and 3 (11%) declined transplant. Three caregivers (11%) thought that the patient did not fully understand the reason for transplant referral. Five (18%) thought that the patient did not fully understand potential risks. Ten (36%) thought that alternatives were not fully understood. The only alternatives to transplant identified, progressive illness and the possibility of earlier death without transplant, were unacceptable to most. Thirteen caregivers (46%) reported that the patient thought that declining transplant was not an option. Caregivers described the decision as “easy” for 19 (68%), often expressing a sentiment of “do or die.” Those who described the decision as “easy” recalled fewer elements of informed decision making.

From caregivers' reports, patients with cystic fibrosis may not fully understand risks of and alternatives to lung transplantation. Because a strong desire to prolong life necessitates honest communication about potential outcomes, interventions are needed to facilitate high-quality decision making.

An institutional priority toward transplantation, dedicated team dynamics, aggressive clinical growth, and optimal care practices are essential for delivering exceptional care to transplant patients. The importance of multidisciplinary integration of these priorities throughout the continuum of patient care is widely recognized in the transplant arena as well as by the Centers for Medicare and Medicaid Services (CMS). In fact, it is the collaboration within these aspects of care that is necessary for certification by CMS.

To establish institution-wide practices, systems, and mechanisms to optimize performance of transplant centers through the use of evidence-based protocols, clinical innovation, and data-driven quality improvements. To develop training programs and competency based orientation addressing the topics needed for transplant nurses, multidisciplinary caregivers, and clinical transplant coordinators who provide care to transplant patients. To comply with the CMS conditions of participation for transplant centers.

Formation of a renal transplant council and multidisciplinary care team. Flow chart of hospital course from admission to discharge, carefully examining patients' progression through the continuum of care, assessing for barriers to care and knowledge deficits of transplant practitioners.

Development of multiple clinical process improvements resulting in the creation of an environment for continuous learning, optimal transplant care, and exceptional outcomes in transplantation as well as compliance with CMS conditions of participation for transplant centers.

To describe the appropriateness and safety of induction immunosuppression for patients at risk for fatal rejection, and to describe the safety and effectiveness profiles of the induction regimens available in the United States.

MEDLINE/PubMed database, EMBASE database, Google Scholar; references from pertinent articles were also reviewed to identify additional data.

A systematic literature review from January 1, 1980, through June 30, 2008, was performed. Included articles ranged from case series to prospective randomized controlled double-blind placebo-controlled trials that detailed the following topics with respect to induction immunosuppression: risk of fatal rejection, renal sparing, malignancy, OKT3, rabbit or equine antithymocyte globulin, daclizumab, basiliximab, and alemtuzumab.

Patients at highest risk for fatal rejection experienced a survival benefit from induction immunosuppression, whereas all other patients experienced no benefit or harm. Most of the early data detail positive experiences with polyclonal antibody regimens. Several newer trials compare the use of polyclonal strategies with the use of anti-CD25 targeted monoclonal antibodies. Few researchers have assessed the usefulness of an anti-CD52 approach. Overall, induction therapy remains a poorly studied and widely variable practice among the major US heart transplant centers.

At present, the unrestricted use of induction for all patients does not seem prudent. Induction should be individualized for each patient on the basis of a well-designed protocol, careful analysis of the transplant center's demographics, and the effectiveness and safety profiles of the regimens used.

Research on organ donation education is limited by its reliance on convenience samples (ie, small sample sizes and local schools) and its failure to assess methods of instruction on the topic.

To describe medical and nursing students' training in organ donation by examining curriculum content and methods of instruction by using a national sample of medical schools and a statewide sample (New York) of nursing schools.

Self-report online survey.

Nursing and medical deans responsible for curriculum development and evaluation.

Participants provided information on the inclusion of specific topics in organ donation, skills related to organ donation, and the declaration of personal donation intentions within their respective educational programs. Methods of instruction on such topics (eg, standardized patients, lectures, small groups) also were assessed.

Although many educational programs include an organ donation component, a significant proportion of schools failed to provide instruction on donation consent processes, definitions of brain and cardiac death, and the discussion of organ donation during a routine health care visit. Most schools rely on lectures as the sole method of instruction. Recommendations are made for how deficits in instruction might be addressed through future interventions and education.

Intravenous levothyroxine therapy decreases vasopressor requirements and prevents cardiovascular collapse in hemodynamically unstable patients eligible for organ donation. The stability of levothyroxine when used in this manner is unknown.

To determine the stability of levothyroxine solution for intravenous use at a concentration of 0.4 μg/mL diluted in 0.9% sodium chloride.

Triplicate sample sets were prepared by reconstituting levothyroxine 200 μg for injection with 5 mL of 0.9% sodium chloride with further dilution in 500 mL of 0.9% sodium chloride. One sample set was protected from light and the other was left unprotected. Both sample sets were stored at room temperature, and samples from each were analyzed for initial concentration and 4, 8, 12, and 24 hours later.

Levothyroxine sodium 0.4 μg/mL in 500 mL 0.9% sodium chloride is stable for 24 hours at room temperature when protected from light.

Understanding how organ donors' families recover from their grief can help organ procurement organizations improve consent rates and increase the number of deceased donor organs available for transplant.

To determine what helps the loved ones of deceased organ donors heal from their grief and loss, and to better understand families' needs during the consent process as a way of improving overall consent rates for organ donation.

Written survey of all organ and tissue donors' families in the San Diego and Imperial County (California) service area during 2006 and 2007.

Responses to the 20-question survey addressing factors that help healing from grief, as well as contextual information about the families' experience at the hospital and the consent process.

Most respondents (84%) indicated that family support was the most helpful thing in dealing with their grief, followed by the support of friends (74%) and religious and cultural beliefs (37%). Most (75%) indicated that they agreed to donation so that something positive could result from their loss. Most respondents (93%) felt that they were given enough information to make an informed decision about donation, and 6% indicated that the donation process interfered with funeral or memorial arrangements. More than 95% understood that their loved one had died before they were approached for consent. Consistent with previous studies, 12% said they still had unanswered questions about aspects of donation, and 15% of respondents indicated that the discussion about organ donation added more emotional stress to their overall experience.

All organ exchange organizations are challenged to maximize the utilization rate of all donors.

To investigate the benefit of a rescue allocation policy and to study the impact of donor factors on the risk of kidney discard.

All 4057 donors with kidneys offered for allocation to Eurotransplant between 2006 and 2007 were included. Allocation was patient-oriented, based on a point-score system including recipient and donor factors. If an organ offer was rejected 5 times for medical reasons, allocation was switched to rescue allocation (ie, the organ was then offered in a center-oriented way). A logistic regression model was built to test whether donor factors were predictors of rescue allocation or kidney discard.

Rescue allocation was used for 665 donors (16.4%); within this group, transplant rate was 54.3%, resulting in a donor discard rate of 304 donors (7.5% of total study group). The multivariate model showed that rescue allocation was used significantly more for kidneys from child donors and donors with a high creatinine level. Moreover, testing positive for hepatitis B surface antigen or antibody to hepatitis C virus was associated with an increased probability of rescue allocation. Kidney discard was significantly associated with donation after cardiac death, donor age, serum creatinine level, history of diabetes, and history of hepatitis.

Rescue allocation is effective in lowering donor discard rates. Even with rescue allocation, several donor factors were significantly associated with a higher discard rate. Use of liberal donor criteria and a rescue allocation policy can reduce kidney discards and thus shorten the waiting list for kidney transplantation.

Nursing personnel are fundamental in the organ donation and transplantation process, and their attitude toward donation has a decisive effect on patients, patients' families, and the general public.

To analyze the attitudes of nursing personnel toward donation in a transplant hospital and the factors that determine those attitudes.

A random sample of 305 nurses in different hospital services was taken and stratified by type of service. A validated psychosocial questionnaire was used to evaluate attitudes toward donation. The survey was completed anonymously and was self-administered. Student t test, χ² test, and logistic regression analysis were used for statistical analysis.

Most respondents (63%) favored organ donation. The following variables affected attitude: (1) having a favorable attitude toward donation of a family member's organs (P < .001), (2) knowing the concept of brain death (P < .001), (3) having discussed organ donation and transplantation within the family (P = .001), (4) having a favorable attitude toward autopsy (P = .006), (5) fearing mutilation of the body (P < .001), (6) a partner's attitude toward organ donation and transplantation (P < .001), and (7) the respondent's religion (P = .009). Multivariate analysis yielded the following significant factors: (1) fear of mutilation of the body (odds ratio, 9.5), (2) partner's attitude toward organ donation and transplantation (odds ratio, 0.2), and (3) respondent's religion (odds ratio, 2.7).

Attitudes toward organ donation among nurses are similar to attitudes of the general public in Spain. Given the influence of nurses on the general public, promotional campaigns directed at nurses are a priority.