Progress in Transplantation

Some living kidney donors report lost income during recovery from surgery. Little is known about whether concern for living donor’s lost income affects the decision to undergo donation evaluation and the willingness of transplant candidates to discuss living kidney donation (LKD) with others.

To examine whether transplant patients were told by potential donors about lost income concerns and whether patients chose not to discuss LKD with others due to lost income concerns.

Kidney transplant patients (185 wait-listed candidates, 171 deceased donor recipients, and 100 live donor recipients) at 2 centers completed a questionnaire to assess whether concern about donor’s lost income was a consideration in discussion about LKD with others.

One-third (32%) were told by a family member/friend that they were willing to donate but were concerned about potential lost income. The majority of those who expressed financial concern (64%) did not initiate donation evaluation. Many patients (42%) chose not to discuss living donation with a family member/friend due to concern about the impact of lost income on the donor. In the multivariable model, lower annual household income was the only statistically significant predictor of both having a potential donor expressing lost income concern and choosing not to talk to someone because of lost income concern.

Findings from the current study underscore how concern about income loss for living donors may affect decision-making by both transplant candidates and potential donors.

Current policies require very limited informational disclosure between living kidney donors and recipients regardless of the relationship type. No specific policies exist to suggest that exchange/chain donors and their recipients should be treated differently. We surveyed transplant professionals (surgeons and nephrologists) and members of the National Kidney Foundation (NKF) to determine their support for disclosing to donors the health, health behavior, and social information of their exchange/chain donors and exchange/chain recipients.

Twenty questions regarding disclosing to donors information about both their exchange/chain donors and exchange/chain recipients were included in 2 larger surveys on disclosure about kidney transplantation. Survey A was sent electronically to NKF list-servs, and survey B was sent to transplant professionals both electronically and by postal mail.

Survey A yielded 236 valid surveys from NKF donors and recipients (lay stakeholders). Survey B yielded 111 valid surveys from transplant professionals. Both sets of stakeholders support disclosing to donors some health and health behavior information of their exchange/chain donor and exchange/chain recipient, and mostly oppose disclosure of social information. Lay stakeholders favored disclosing significantly more information than transplant professionals. Among lay stakeholders, donor respondents were more supportive than recipient respondents in disclosing to donors health information about the exchange/chain recipient. Among transplant professionals, surgeons were more supportive than nephrologists in disclosing to donors information about the exchange/chain recipient that may impact graft survival.

There is broad stakeholder support for disclosing some health and health behavior information to donors about their exchange/chain donors and recipients.

Mature adults represent an important audience segment for organ donation practitioners. Despite their potential impact as organ donors, compared to other age demographics, their registration rates are much lower.

The objective of the current campaign was to determine the most effective source and message strategy to promote organ and tissue donation among mature adults.

A 2 (states: Illinois and Iowa) by 2 (sources: government agency and organ procurement organization [OPO]) by 3 (taglines: Any age is the right age to share the gift of life, Don’t rule yourself out, and Don’t rule yourself out: Any age is the right age to share the gift of life) between-subjects design was used to test the effectiveness of direct mailings promoting organ donation to mature adults.

Across both Illinois and Iowa, the results revealed that greater organ donation registration rates emerged following exposure to direct mail authored by a state official such as the Illinois Secretary of State or the Iowa Department of Public Health compared to local OPOs.

Overall, the findings speak to the effectiveness of direct mail marketing campaign’s ability to register potential organ donors. Moreover, the results reveal that it is more important who sends the message as opposed to what the message states.

Tacrolimus requires close therapeutic drug monitoring (TDM) to ensure efficacy and minimize adverse effects. Pharmacists are uniquely positioned on transplant teams to interpret levels and recommend therapy modifications. Their impact in the immediate postoperative setting has not been described previously.

To evaluate the impact of a clinical solid organ transplant pharmacist on nephrotoxicity, TDM, and revenue generation in adult kidney transplant recipients on tacrolimus.

Retrospective assessment of adult kidney transplant recipients at University of Florida Health Shands Hospital.

A transplant pharmacist rounded 5 days a week and made medication recommendations on transplant recipients—including tacrolimus dose modifications based on levels. Pharmacy services were expanded to include medication reconciliation, medication counseling, and delivery of discharge medications to bedside.

Incidence of nephrotoxicity during tacrolimus exposure.

Of the 70 kidney transplant recipients in the postpharmacist cohort, 18 (25.7%) experienced nephrotoxicity while on tacrolimus, compared to 18 (25%) of the 72 in the prepharmacist cohort (P = .922). A significantly greater proportion of recipients who experienced nephrotoxicity were male, had hypertension, or experienced delayed or slow graft function. The rate of appropriately drawn tacrolimus troughs significantly increased from 23.4% to 30.3% in the postpharmacist cohort (P < .001). The median outpatient pharmacy revenue generated per recipient significantly increased from US$345.49 (interquartile range [IQR]: 0-4727.56) to US$4834.95 per recipient (IQR: 3592.78-6224.60; P < .001). The length of stay (7 days, IQR: 6-9, vs 8 days, IQR: 6-9; P = .107) and the 30-day readmission rate were similar between groups (20.8% vs 21.4%; P = .931).

Adequate patient education is essential for preparing potential recipients for kidney transplantation. Health-care providers play a vital role in education and can identify gaps in patient understanding.

To identify deficits in patient knowledge from the perspective of a transplant multidisciplinary care team and determine whether their perceptions align with patients who have previously undergone a transplant.

An open call was advertised for health-care providers to attend a focus group discussion regarding the educational needs of pretransplant patients in 1 Canadian center. A predetermined, semistructured set of questions was used to collect the views of transplant caregivers. A moderator, assistant moderator, and research assistant facilitated the discussion, which was transcribed verbatim. Paper surveys were distributed to collect opinions of those unable to attend or uncomfortable to voice their opinion in an open forum. Qualitative analysis software was used to identify any emergent themes. Results were compared to a previous study undertaken in transplant recipients.

Despite pre- and posttransplant education, specific themes emerged including misconceptions about the assessment process and time on the wait list and the surgery, incongruency between patient expectations and outcome, and confusion regarding medications. Health-care provider perceptions were remarkably consistent with transplant recipients.

Health-care providers identified gaps in patient understanding indicating that transplant candidates may not be internalizing what is taught. Innovative educational approaches may be needed to provide more successful patient education. Similarities between health-care provider and patient perceptions suggest that care providers are a valuable source of information.

Patients travel worldwide for paid kidney transplants. Although transplantations abroad are not always illegal, they are commonly perceived to be illegal and unethical involving risks.

We aimed to describe the motivations and experiences of patients who traveled abroad for paid kidney transplantations and to examine how these transplantations were facilitated.

We interviewed 22 patients who traveled from Macedonia/Kosovo, the Netherlands, and Sweden for paid kidney transplantations between years 2000 and 2009.

Patients traveled because of inadequate transplant activity in their domestic countries and dialysis-related complaints. However, 6 patients underwent preemptive transplantations. Cultural factors such as patients’ affinity with destination countries, feelings of being discriminated against by the health-care system, and family ties also help explain why patients travel abroad. Seven of the 22 patients went to their country of origin. They were able to organize their transplantations by arranging help from family and friends abroad who provided contacts of caregivers there and who helped cover the costs of their transplants. The costs varied from €5000 to €45 000 (US$6800-US$61 200). Seven patients paid the hospital, 5 paid their doctor, 4 paid a broker, and 6 paid their donors.

Research should include interviews with brokers, transplant professionals, and other facilitators to achieve a full picture of illegally performed transplantations.

Endocan is a marker showing endothelial dysfunction and inflammation. Significantly increased endocan levels have been observed in serum of patients with sepsis and cancer.

Our aim was to investigate the relationship between vitamin D treatment and serum endocan and high-sensitivity C-reactive protein (hs-CRP) levels as inflammatory markers in transplant patients.

Prospective.

Nephrology clinic.

Thirty-eight renal transplant patients with serum 25-hydroxy-vitamin D (25-OH-vitamin D) levels below 20 ng/mL and transplanted at least 12 months.

One-time oral dose of 300 000 IU vitamin D3.

Before and after vitamin D treatment, serum endocan, hs-CRP, calcium, phosphorus, and parathyroid hormone (PTH) levels were measured.

Median serum endocan and PTH values before vitamin D were significantly higher than those of after treatment values (P = .001 and P < .001, respectively). On the other hand, serum total calcium and phosphorus levels before vitamin D treatment were lower than the values obtained after vitamin D treatment (P = .0013 and P < .001, respectively). Serum hs-CRP was lower after vitamin D therapy than before, but the difference was not statistically significant (P = .06). A moderate negative correlation was determined between endocan and 25-OH-vitamin D levels after treatment with vitamin D (r = −.36, P = .02).

This study has revealed that vitamin D treatment reduced markers of endothelial dysfunction in patients with renal transplantation and vitamin D deficiency.

Nations with emerging deceased-donor liver transplantation programs, such as India, face problems associated with poor donor maintenance. Cold ischemic time (CIT) is typically maintained short by matching donor organ recovery and recipient hepatectomy to achieve maximum favorable outcome. We analyzed different extended criteria donor factors including donor acidosis, which may act as a surrogate marker of poor donor maintenance, to quantify the risk of primary nonfunction (PNF) or initial poor function (IPF).

A single-center retrospective outcome analysis of prospectively collected data of patients undergoing deceased-donor liver transplantation over 2 years to determine the impact of different extended criteria donor factors on IPF and PNF.

From March 2013 to February 2015, a total of 84 patients underwent deceased-donor liver transplantation. None developed PNF. Thirteen (15.5%) patients developed IPF. Graft macrosteatosis and donor acidosis were only related to IPF (P = .002 and P = .032, respectively). Cold ischemic time was maintained short (81 cases ≤8 hours, maximum 11 hours) in all cases.

Poor donor maintenance as evidenced by donor acidosis and graft macrosteatosis had significant impact in developing IPF when CIT is kept short. Similar study with larger sample size is required to establish extended criteria cutoff values.

The management of hepatocellular carcinoma (HCC) recurrence after liver transplantation (LT) is challenging, especially if it is not treatable by surgery or embolization.

The present study aims to compare the survival rates of liver transplanted patients receiving sorafenib or best supportive care (BSC) for HCC recurrence not amenable to curative intent treatments.

This is a retrospective comparative study on a prospectively maintained database.

Liver transplanted patients with untreatable HCC recurrence receiving BSC (n = 18) until 2007 or sorafenib (n = 15) thereafter were compared.

No group difference was observed for demographic characteristics at the time of transplantation and at the time of HCC recurrence. On the explant pathology of the native liver, 81.2% patients were classified within the Milan criteria, and 53.1% presented with microvascular invasion. Hepatocellular carcinoma recurrence was diagnosed 17.8 months (standard deviation: 14.5) after LT, with 17 (53.1%) patients presenting with early recurrence (≤12 months). The 1-year survival from untreatable progression of HCC recurrence was 23.9% for the BSC and 60% for the sorafenib group (P = .002). The type of treatment (sorafenib vs BSC) was the sole independent predictor of survival (hazard ratio: 2.98; 95% confidence interval: 1.09-8.1; P = .033). In the sorafenib group, 8 (53.3%) patients required dose reduction, and 2 (13.3%) patients discontinued the treatment due to intolerable side effects.

Sorafenib improves survival and is superior to the BSC in cases of untreatable posttransplant hepatocellular carcinoma recurrence.

Improvements in transplantation have increased the survival of children after kidney transplantation. These patients have complex needs, and the current medical system is not prepared to effectively transfer the care of these individuals from pediatric to adult health-care systems. Too often, transfer occurs during moments of crisis and is associated with poor outcomes.

The aim of this study was to use a national database, the Scientific Registry of Transplant Recipients, to test the hypothesis that the increased risk of graft loss after transfer of care (from pediatric to adult services) for young adult kidney transplant recipients over a 2- to 3-year posttransfer follow-up period was related to these posttransfer risk factors (medication noncompliance, acute rejection, insurance status).

A retrospective, longitudinal, correlational design using secondary data was used to evaluate the transfer of care of 250 kidney transplant recipients (ages 16-25).

Seventy-seven (30.8%) individuals lost their graft within 3 years after transfer of care. Medication noncompliance, acute rejection, and serum creatinine >2.0 mg/dL at transfer were significant predictors of graft loss after accounting for multiple other factors.

These individuals are at risk for graft loss after transfer of care and may benefit from increased personalized care during this risky period.

Sodium retention causes posttransplant hypertension, and sodium restriction is recommended in kidney allograft recipients. However, there have been few studies on the impact of dietary counseling on sodium intake and blood pressure (BP) in this population.

To determine the effect of dietary counseling on sodium intake and consequent BP control in kidney allograft recipients.

A prospective single-arm study to determine the effect of dietary counseling on sodium intake. Enrolled were renal allograft recipients with sodium intake >100 mEq/d, BP >130/80, antihypertensive use, or body mass index >25 kg/m². Of 53 renal transplant recipients who met the criteria, 48 participated in the present study. Sodium intake was estimated based on 24-hour urinary sodium excretion before and after 3 sessions of dietary counseling by a board-certified dietitian.

Sodium intake was significantly decreased after dietary counseling (158.7 vs 129.6 mEq/d; P = .005). Systolic BP was significantly decreased from 124 mm Hg (interquartile range: 122-134) before counseling to 121 mm Hg (interquartile range: 117-128) after counseling (P < .001). The number of patients with systolic BP >130 mm Hg was decreased by 30% (n = 19-13; P = .07). Among 34 patients on antihypertensive medications, 8 (23.5%) ceased or reduced their drugs due to improvement in BP, whereas 2 increased or changed the drugs due to poor control of BP.

Dietary counseling showed a short-term efficacy of reducing sodium intake and clinically relevant BP improvement in renal allograft recipients.

A department of forensic medicine (DFM) can be a valuable source for tissue donation, but logistics can prove difficult to overcome as it pertains to obtaining tissues for donation. This article describes the potential of tissues that can be procured for transplantation.

Sweden has 9.7 million inhabitants, with an annual mortality rate of 90 000 and 5500 medicolegal autopsies per year. Cooperation between tissue banking and 2 DFMs began in the mid-1980s. Recently, cooperation has expanded to include all six DFMs. All tissue establishments (TEs) were asked to complete a questionnaire concerning their cooperation with DFMs from 2011 through 2013.

A total of 298 actual donors were identified; 1090 tissues were procured including cardiovascular tissue, cornea, sclera, ear bones, and skin for transplantation. Of the tissues distributed, 553 were for transplantation and 72 for other medical purposes. Twenty-three percent of the tissues were discarded. Reasons for tissue rejection included deficient tissue quality (65%), positive serology tests (9%), positive bacteriology tests after decontamination procedures (7%), technical errors (<1%), and other reasons (18%).

Nineteen percent of all tissues distributed for transplantation came from donors in DFMs. The cooperation between DFMs and TEs was described as well functioning and excellent. Education and national courses in tissue procurement for employees in DFMs are contributing factors to such positive interactions. The support from the National Board of Forensic Medicine is an important factor for sustainable progress.

To establish the current state of knowledge regarding physical activity interventions for adult kidney transplant recipients.

A comprehensive literature search was conducted for the years 2009 to 2015 using 5 electronic databases: PubMed, CINAHL, Cochrane Library, Ovid, and ScienceDirect.

Of the 110 articles identified, only 6 met inclusion requirements. These studies were conducted between 2009 and 2015 and found that weight gain was reported most often within the first year of transplantation and that kidney transplant recipients desired early interventions to help them become more physically active.

Further research is recommended to design age-appropriate physical activity interventions among this aging population living with a chronic condition known to have a high prevalence of obesity and cardiovascular disease.