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Restricted accessEditorialFirst published December, 2013pp. 300-301
Restricted accessResearch articleFirst published December, 2013pp. 302-309Barriers to kidney transplant for African Americans are well documented in the literature. Little information on ownership of information and communication technology and use of such technology in transplant populations has been published.
To characterize racial differences related to ownership and use of information and communication technology in kidney transplant patients.
A single-center, cross-sectional survey study.
An urban Midwestern transplant center.
78 pretransplant patients and 177 transplant recipients.
The survey consisted of 6 demographic questions, 3 disease-related questions, and 9 technology-related questions. Dichotomous (yes/no) and Likert-scale items were the basis for the survey.
Cell phone use was high and comparable between groups (94% in African Americans, 90% in whites,
The use of cell phone technology and text messaging was ubiquitous and comparable between groups, but computer and Internet access and frequency of use were not. Reaching out to the African American community may best be accomplished by using cell phone/text messaging as opposed to Internet-based platforms.
Restricted accessResearch articleFirst published December, 2013pp. 310-318Alcohol relapse after liver transplant heightens concern about recurrent disease, nonadherence to the immunosuppression regimen, and death.
To develop a scoring system to stratify risk of alcohol relapse after liver transplant.
Retrospective medical record review.
All adult liver transplants performed from May 2002 to February 2011 at a single center in the United States.
The incidence of return to any alcohol consumption after liver transplant.
Thirty-four percent (40/118) of patients with a history of alcohol abuse/dependency relapsed to use of any alcohol after liver transplant. Nine of 25 hypothesized risk factors were predictive of alcohol relapse after liver transplant: absence of hepatocellular carcinoma, tobacco dependence, continued alcohol use after liver disease diagnosis, low motivation for alcohol treatment, poor stress management skills, no rehabilitation relationship, limited social support, lack of nonmedical behavioral consequences, and continued engagement in social activities with alcohol present. Each independent predictor was assigned an Alcohol Relapse Risk Assessment (ARRA) risk value of 1 point, and patients were classified into 1 of 4 groups by ARRA score: ARRA I = 0, ARRA II = 1 to 3, ARRA III = 4 to 6, and ARRA IV = 7 to 9. Patients in the 2 higher ARRA classifications had significantly higher rates of alcohol relapse and were more likely to return to pretransplant levels of drinking.
Alcohol relapse rates are moderately high after liver transplant. The ARRA is a valid and practical tool for identifying pretransplant patients with alcohol abuse or dependency at elevated risk of any alcohol use after liver transplant.
Restricted accessResearch articleFirst published December, 2013pp. 319-328Knowing the prevalence and risk factors of immunosuppression nonadherence after liver transplant may help guide intervention development.
To examine whether sociodemographic and psychosocial variables before liver transplant are predictive of nonadherence after liver transplant.
Structured telephone interviews were used to collect self-report immunosuppression adherence and health status information. Medical record reviews were then completed to retrospectively examine the relationship between immunosuppression adherence and pretransplant variables, including sociodemographic and medical characteristics and the presence or absence of 6 hypothesized psychosocial risk factors.
A nonprobability sample of 236 adults 6 to 24 months after liver transplant at 2 centers completed structured telephone interviews.
Immunosuppressant medication nonadherence, categorized as missed-dose and altered-dose “adherent” or “nonadherent” during the past 6 months; immunosuppression medication holidays.
Eighty-two patients (35%) were missed-dose nonadherent and 34 patients (14%) were altered-dose nonadherent. Seventy-one patients (30%) reported 1 or more 24-hour immunosuppression holidays in the past 6 months. Missed-dose nonadherence was predicted by male sex (odds ratio, 2.46;
Rates of immunosuppressant nonadherence and drug holidays in the first 2 years after liver transplant are unacceptably high. Pretransplant mood disorder and social support instability increase the risk of nonadherence, and interventions should target these modifiable risk factors.
Restricted accessResearch articleFirst published December, 2013pp. 329-335Because of the nature of the helping professions, nurses are at high risk for compassion fatigue and burnout. In the past, many researchers have studied compassion fatigue and burnout in nurses. However, reports of research assessing liver and kidney transplant nurse coordinators' compassion fatigue and burnout are rare.
To assess liver and kidney transplant nurse coordinators' levels of compassion fatigue and burnout.
A nonexperimental, exploratory descriptive study was conducted using the Professional Quality of Life Scale Version 5 (ProQOL-V), a 30-item self-report instrument to measure participants' level of compassion satisfaction, burnout, and secondary traumatic stress.
This study sampled 14 liver and kidney transplant nurse coordinators from a large multiorgan transplant center in the Southeast region.
Transplant nurse coordinators had an average level of compassion satisfaction, an average level of burnout, and an average level of secondary traumatic stress. Within liver and kidney transplant nurse coordinators, a statistically significant relationship was found between education levels of transplant nurse coordinators and the level of burnout, suggesting that education levels may influence burnout.
Restricted accessResearch articleFirst published December, 2013pp. 336-341Respiratory therapists provide care for every potential organ donor but do not receive formal education regarding organ procurement.
To assess the number of respiratory therapists who are aware of the organ donor referral criteria and their attitude toward organ donation before and after an organ procurement organization provided an educational course.
A retrospective analysis of surveys following an educational course.
Hospital respiratory therapy departments within the Texas Organ Sharing Alliance northern region.
Respiratory therapists who attended the educational course.
Measured outcomes were respiratory therapists' attitude scores before and after the organ procurement organization provided the educational course, the number of organ donor cases experienced during the respiratory therapists' careers, the unit(s) of the hospital in which the respiratory therapists worked, and the respiratory therapists' awareness of the organ donor referral criteria before the organ procurement organization provided the educational course.
Seventy-seven respiratory therapists were surveyed. Sixty-two respiratory therapists identified themselves as working in a critical care setting and 58% stated they were unaware of the donor referral criteria. Seventeen respiratory therapists reported their attitude toward organ donation improved with no perception decline. Using the Wilcoxon signed rank test for statistical analysis, the mean attitude score after the education course was significantly different at an alpha level of 0.05 (
Restricted accessResearch articleFirst published December, 2013pp. 342-349The benefits and disadvantages of posttransplant contact between a donor family and the organ recipient are disputed. In this study far more contacters reported benefits rather than disadvantages and noncontacters reported the opposite. The dissatisfaction of noncontacters with no contact was high: no less than 60% wanted some form of contact in the future. The authors conclude that contact has more benefits for the donor family than disadvantages, evidenced by families' desire to maintain contact with the organ recipient. Both donor families and organ recipients need the transplant coordinator's initiative and guidance on this issue.
Restricted accessResearch articleFirst published December, 2013pp. 350-364Organ transplant centers are under increasing scrutiny to maintain outcomes while controlling cost in a challenging population of patients. Throughout health care and transplant specifically, length of stay is used as a benchmark for both quality and resource utilization.
To decrease our length of stay for liver transplant by using Lean Six Sigma methods.
The Six Sigma DMAIC (Define, Measure, Analyze, Improve, Control) method was used to systematically analyze our process from transplant listing to hospital discharge after transplant, identifying many factors affecting length of stay.
Adult, single-organ, primary liver transplant recipients between July 2008 and June 2012 were included in the study. Recipients with living donors or fulminant liver failure were excluded.
Multiple interventions, including a clinical pathway and enhanced communication, were implemented.
Length of stay after liver transplant and readmission after liver transplant.
Median length of stay decreased significantly from 11 days before the intervention to 8 days after the intervention. Readmission rate did not change throughout the study. The improved length of stay was maintained for 24 months after the study.
Using a Lean Six Sigma approach, we were able to significantly decrease the length of stay of liver transplant patients. These results brought our center's outcomes in accordance with our goal and industry benchmark of 8 days. Clear expectations, improved teamwork, and a multidisciplinary clinical pathway were key elements in achieving and maintaining these gains.
Restricted accessResearch articleFirst published December, 2013pp. 365-367Granulomatous diseases are a rare cause of hypercalcemia. The pathogenesis is presumed to be from endogenous production of 1,25-dihydroxyvitamin D by activated macrophages in granulomatous lesions, which harbor the 1 α-hydroxylase enzyme. Herein the first case of hypercalcemia associated with giant cell myocarditis, an unusual type of granulomatous process, is reported. In this case, a patient with giant cell myocarditis had development of progressive heart failure and cardiorenal syndrome that required biventricular support. One year later, hypercalcemia associated with a relatively high 1,25-vitamin D level and a concomitantly suppressed parathyroid hormone level developed in the presence of stage 4 chronic kidney disease. Her other workup of hypercalcemia was unrevealing for vitamin D intoxication and multiple myeloma. Computed tomography of her chest showed no signs of hilar lymphadenopathy. Her calcium levels returned to normal with low-dose steroid therapy and have remained normal following a successful heart transplant. This case illustrates an unusual cause of hypercalcemia thought to be due to extrarenal calcitriol production associated with giant cell myocarditis.
Restricted accessResearch articleFirst published December, 2013pp. 368-370An adolescent female received an isolated intestinal transplant. She developed severe exfoliative rejection and required complete enterectomy. The patient developed a septic hip and lung lesions with biopsy-proven
Restricted accessResearch articleFirst published December, 2013pp. 371-373Kawasaki disease is a systemic vascular inflammatory disorder of yet unknown cause that is associated with critical cardiovascular complications. Several long-term medical therapies, coronary revascularization, and heart transplant have been introduced to treat coronary artery lesions. This report describes a 20-year-old man with Kawasaki disease manifesting as intermittent chest pain and nausea who had advanced decompensated cardiomyopathy (ejection fraction, 15%) diagnosed. Coronary artery bypass surgery and implantation of a cardioverter defibrillator had been performed, although no significant clinical improvement was observed. Finally, a successful orthotopic bicaval heart transplant was performed. Follow-up examination after 1 year revealed normal cardiac function with no evidence of organ rejection. This experience demonstrated that heart transplant might be a successful method of treating permanent ischemic cardiomyopathy in patients with Kawasaki syndrome.
Restricted accessResearch articleFirst published December, 2013pp. 374-382Catecholamines and inflammatory mediators, with elevated levels after brain death, are associated with reduced function and survival of transplanted organs. Enteral nutrition reduces tissue damage and may benefit organs.
To evaluate the effects of immunomodulating enteral nutrition in organ donors.
Prospective, randomized, open-label study.
Intensive care unit.
Thirty-six brain-dead organ donors.
Donors were randomized to receive enteral nutrition containing omega-3 polyunsaturated fatty acid, antioxidants, and glutamine or standard care (fasting). Donors received hormonal replacement therapy of corticosteroid, levothyroxine, dextrose, and insulin.
Gastrointestinal assimilation (measured by 13carbon-labeled uracil breath analysis), quantity of organs recovered, resting energy expenditure, urine level of urea nitrogen, and serum levels of albumin, prealbumin, interleukin 6, tumor necrosis factor-α, and C-reactive protein were evaluated.
Thirteen patients (36%) assimilated 13C-labeled uracil. Resting energy expenditure was significantly higher than predicted between 10 and 14 hours after baseline in 33 donors (
About 30% of donors metabolized 13C-labeled uracil, although no difference in oxidation rate was found between fasting and fed donors. Corticosteroid administration lowers plasma levels of interleukin 6 and most likely contributes to greater than predicted resting energy expenditure. Thus energy needs may not be met during fasting if hormones are given. Consequences of this possible energy deficit warrant further study.
Restricted accessResearch articleFirst published December, 2013pp. 383-391Various preservation solutions are used for kidney, liver, pancreas, small intestine, and multiorgan recoveries and transplants. The effectiveness of these solutions, primarily measured by ability to preserve the organ and graft survival, was analyzed. The 2 most common solutions used for intra-abdominal organs are University of Wisconsin Solution (UW)/Viaspan and Histidine-tryptophan-ketoglutarate (HTK)/Custodiol solution. Outcomes for liver, pancreas, and kidney allografts preserved with these 2 solutions are similar. Although HTK solution shows conflicting results with respect to pancreatic cellular edema, researchers in several studies have noted that HTK solution may be more protective than UW solution against biliary complications in liver transplant. In kidney recoveries, HTK solution may be associated with higher graft loss and increased delayed graft function in marginal deceased donors but had lower incidence of delayed graft function in living donors when compared with UW. UW remains the reference standard for use during multiorgan recoveries but is experiencing strong competition from HTK and other alternative solutions. Some researchers suggest that Celsior's comparable results in abdominal organs and viability for thoracic organs makes it a strong competitor, especially in multiorgan recoveries. Each solution has benefits accompanied by disadvantages. Although it may not be feasible, when considering single-organ recoveries, consideration of alternative solutions may be warranted.
Restricted accessResearch articleFirst published December, 2013pp. 392-400The Modified Transplant Symptom Occurrence and Symptom Distress Scale-59 Items Revised (MTSOSD-59R) is a validated self-reported scale assessing patients' subjective experiences of adverse effects of immunosuppressants. It has been reported that the scale should be adapted and validated before it is used in patients of a different cultural (Brazilian, Dutch, German, French, Hindi, Italian, Spanish, and Swedish) background.
To validate and adapt the MTSOSD-59R for use in Turkish transplant recipients.
This cross-sectional study was performed between March 2010 and February 2011, and included 180 liver and kidney transplant recipients treated in 2 university hospitals in western Turkey. In addition, 180 healthy control participants were recruited from a community health service. Data were collected by using a demographic and clinical characteristics scale (MTSOSD-59R) and the Beck Depression Inventory. Items were translated in a culturally sensitive way by using forward-backward translation. Content validity was evaluated by using the content validity index. Ridit analysis and descriptive statistics helped to describe symptom experience in our population, and Mann Whitney
The content validity index was perfect (ie, value 1.0); the Turkish translation of the MTSOSD-59R had excellent known group validity. Split-half Spearman Brown corrected reliability coefficient was 0.991 for symptom occurrence and 0.992 for symptom distress.
The results suggest that the Turkish scale has appropriate language, content, and construct validity. This scale can now be used to assess the symptom experience related to immunosuppressive therapy in Turkish organ transplant recipients.