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Graft Function and Intermediate-Term Outcomes of Kidney Transplants Improved in the Last Decade: Analysis of the United States Kidney Transplant Database.

Sun, 06/18/2017 - 12:45
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Graft Function and Intermediate-Term Outcomes of Kidney Transplants Improved in the Last Decade: Analysis of the United States Kidney Transplant Database.

Transplant Direct. 2017 Jun;3(6):e166

Authors: Keith DS, Vranic G, Nishio-Lucar A

Abstract
BACKGROUND: Previous analyses of the United States transplant database regarding long-term outcomes in kidney transplantation have shown minimal improvement in the rate of long-term graft loss. This study sought to analyze intermediate-term outcomes and graft function at 6 months in kidney transplantation in adult living and deceased donor recipients in the last decade.
METHODS: Survival analysis was performed based on the year of transplant between 6 months and 3 years' posttransplant. The Chronic Kidney Disease Epidemiology Collaboration estimated glomerular filtration rate (eGFR) was determined at 6 months.
RESULTS: The unadjusted graft survival between 6 months and 3 years improved significantly in the latter half of the decade in both deceased and living donor kidney recipients. Cox analysis showed a 33% reduction in the rate of graft loss and that the improvement in graft survival was due to similar improvements in both death-censored graft and death with graft function survival. A 10% improvement in median eGFR occurred despite worsening donor demographics over time in both donor types. This improvement in eGFR and graft survival occurred in association with a consolidation of chronic discharge immunosuppression from a variety of combinations to over 85% of recipients receiving tacrolimus and mycophenolate derivative immunosuppression.
CONCLUSIONS: In the latter half of last decade graft survival improved in adult kidney transplant recipients. The improvement in graft survival occurred in temporal association with an improvement in median eGFR at 6 months and consolidation of discharge immunosuppression in most patients to tacrolimus and mycophenolate derivatives.

PMID: 28620650 [PubMed - in process]

Kidney Transplant Recipients' Perspectives on Cardiovascular Disease and Related Risk Factors After Transplantation: A Qualitative Study.

Sun, 06/18/2017 - 12:45
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Kidney Transplant Recipients' Perspectives on Cardiovascular Disease and Related Risk Factors After Transplantation: A Qualitative Study.

Transplant Direct. 2017 Jun;3(6):e162

Authors: Ballesteros F, Allard J, Durand C, Cardinal H, Lalonde L, Fortin MC

Abstract
BACKGROUND: Cardiovascular disease (CVD) is a major cause of mortality among kidney transplant recipients (KTRs). These patients have a high prevalence of risk factors, such as hypertension, diabetes, and dyslipidemia. Despite regular medical care, few of them reach the recommended therapeutic targets. The objective of this study is to describe KTRs' perspectives on CVD and related risk factors, as well as their priorities for posttransplant care.
METHODS: Twenty-six KTRs participated in a semistructured interview about their personal experience and offered their perspectives on CVD risk factors posttransplant. The interview was digitally recorded and the transcripts were analyzed using a thematic and content methodology.
RESULTS: CVD and related risk factors appear to be underestimated and trivialized. Only 2 of 26 patients identified CVD prevention and treatment as a priority. The most important posttransplant priorities identified by patients were related to immunosuppressive drugs (13 of 26), posttransplant follow-up (10) and graft survival (9). However, 21 of 26 patients stated they wanted to be better informed about posttransplant CVD risk factors.
CONCLUSIONS: CVD and related risk factors are not a priority for KTRs, and the importance of CVD is underestimated and trivialized. KTRs did recommend that tailored information be provided by various professionals and at several points in the transplantation process. This knowledge will help us develop a new approach to increase awareness of posttransplant CVD and related risk factors.

PMID: 28620646 [PubMed - in process]

Alloimmunity But Not Viral Immunity Promotes Allograft Loss in a Mouse Model of Polyomavirus-Associated Allograft Injury.

Sun, 06/18/2017 - 12:45
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Alloimmunity But Not Viral Immunity Promotes Allograft Loss in a Mouse Model of Polyomavirus-Associated Allograft Injury.

Transplant Direct. 2017 Jun;3(6):e161

Authors: Kim SC, Wang J, Dong Y, Mathews DV, Albrecht JA, Breeden CP, Farris AB, Lukacher AE, Ford ML, Newell KA, Adams AB

Abstract
BACKGROUND: The interplay between viral infection and alloimmunity is known to influence the fate of transplanted organs. Clarifying how local virus-associated inflammation/injury and antiviral immunity can alter host alloimmune responses in transplantation remains a critical question.
METHODS: We used a mouse model of polyomavirus (PyV) infection and kidney transplantation to investigate the roles of direct viral pathology, the antiviral immune response, and alloimmunity in the pathogenesis of PyV-associated allograft injury. We have previously shown that an effective primary T cell response is required in PyV-associated graft injury.
RESULTS: Here we show that the transfer of primed antidonor, but not antiviral, T cells results in PyV-associated allograft injury. In further studies, we use a surrogate minor antigen model (ovalbumin) and show that only antidonor specific T cells and not antiviral specific T cells are sufficient to mediate injury. Lastly, we demonstrate that local but not systemic virus-mediated inflammation and injury within the graft itself are required.
CONCLUSIONS: These data suggest that in this mouse model, the predominant mechanism of allograft injury in PyV-associated injury is due to an augmented alloimmune T cell response driven by virus-induced inflammation/injury within the graft. These studies highlight the important interplay between viral infection and alloimmunity in a model system.

PMID: 28620645 [PubMed - in process]

Advances in the Knowledge about Kidney Decellularization and Repopulation.

Sun, 06/18/2017 - 12:45
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Advances in the Knowledge about Kidney Decellularization and Repopulation.

Front Bioeng Biotechnol. 2017;5:34

Authors: Destefani AC, Sirtoli GM, Nogueira BV

Abstract
End-stage renal disease (ESRD) is characterized by the progressive deterioration of renal function that may compromise different tissues and organs. The major treatment indicated for patients with ESRD is kidney transplantation. However, the shortage of available organs, as well as the high rate of organ rejection, supports the need for new therapies. Thus, the implementation of tissue bioengineering to organ regeneration has emerged as an alternative to traditional organ transplantation. Decellularization of organs with chemical, physical, and/or biological agents generates natural scaffolds, which can serve as basis for tissue reconstruction. The recellularization of these scaffolds with different cell sources, such as stem cells or adult differentiated cells, can provide an organ with functionality and no immune response after in vivo transplantation on the host. Several studies have focused on improving these techniques, but until now, there is no optimal decellularization method for the kidney available yet. Herein, an overview of the current literature for kidney decellularization and whole-organ recellularization is presented, addressing the pros and cons of the actual techniques already developed, the methods adopted to evaluate the efficacy of the procedures, and the challenges to be overcome in order to achieve an optimal protocol.

PMID: 28620603 [PubMed - in process]

Belatacept Does Not Inhibit Follicular T Cell-Dependent B-Cell Differentiation in Kidney Transplantation.

Sun, 06/18/2017 - 12:45
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Belatacept Does Not Inhibit Follicular T Cell-Dependent B-Cell Differentiation in Kidney Transplantation.

Front Immunol. 2017;8:641

Authors: de Graav GN, Hesselink DA, Dieterich M, Kraaijeveld R, Verschoor W, Roelen DL, Litjens NHR, Chong AS, Weimar W, Baan CC

Abstract
Humoral alloreactivity has been recognized as a common cause of kidney transplant dysfunction. B-cell activation, differentiation, and antibody production are dependent on IL-21(+)CXCR5(+)follicular T-helper (Tfh) cells. Here, we studied whether belatacept, an inhibitor of the costimulatory CD28-CD80/86-pathway, interrupts the crosstalk between Tfh- and B-cells more efficiently than the calcineurin inhibitor tacrolimus. The suppressive effects of belatacept and tacrolimus on donor antigen-driven Tfh-B-cell interaction were functionally studied in peripheral blood mononuclear cells from 40 kidney transplant patients randomized to a belatacept- or tacrolimus-based immunosuppressive regimen. No significant differences in uncultured cells or donor antigen-stimulated cells were found between belatacept- and tacrolimus-treated patients in the CXCR5(+)Tfh cell generation and activation (upregulation of PD-1). Belatacept and tacrolimus in vitro minimally inhibited Tfh-cell generation (by ~6-7%) and partially prevented Tfh-cell activation (by ~30-50%). The proportion of IL-21(+)-activated Tfh-cells was partially decreased by in vitro addition of belatacept or tacrolimus (by ~60%). Baseline expressions and proportions of activated CD86(+) B-cells, plasmablasts, and transitional B-cells after donor antigen stimulation did not differ between belatacept- and tacrolimus-treated patients. Donor antigen-driven CD86 upregulation on memory B-cells was not fully prevented by adding belatacept in vitro (~35%), even in supratherapeutic doses. In contrast to tacrolimus, belatacept failed to inhibit donor antigen-driven plasmablast formation (~50% inhibition vs. no inhibition, respectively, p < 0.0001). In summary, donor antigen-driven Tfh-B-cell crosstalk is similar in cells obtained from belatacept- and tacrolimus-treated patients. Belatacept is, however, less potent in vitro than tacrolimus in inhibiting Tfh-cell-dependent plasmablast formation.

PMID: 28620390 [PubMed - in process]

Peri- and Postoperative Treatment with the Interleukin-1 Receptor Antagonist Anakinra Is Safe in Patients Undergoing Renal Transplantation: Case Series and Review of the Literature.

Sun, 06/18/2017 - 12:45
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Peri- and Postoperative Treatment with the Interleukin-1 Receptor Antagonist Anakinra Is Safe in Patients Undergoing Renal Transplantation: Case Series and Review of the Literature.

Front Pharmacol. 2017;8:342

Authors: Mulders-Manders CM, Baas MC, Molenaar FM, Simon A

Abstract
In patients undergoing solid organ transplantation, the presence of an interleukin-1 (IL-1) driven disease may require the addition of IL-1 inhibiting drugs to the standard immunosuppressive regimen to protect against inflammation and negative graft outcome. Three patients undergoing renal transplantation were treated perioperatively with the interleukin-1 receptor antagonist anakinra. Kidney function increased rapidly in all three and the only complications seen were minor infections. In vitro studies report associations between serum and urinary levels of IL-1β and IL-1 receptor antagonist and negative graft outcome, and studies in animals and two small human trials illustrate a possible protective effect of anti-IL-1 therapy after solid organ transplantation. Peri- and postoperative use of anakinra is safe and effective in patients undergoing renal transplantation.

PMID: 28620307 [PubMed - in process]

Bone mesenchymal stem cells ameliorate ischemia/reperfusion-induced damage in renal epithelial cells via microRNA-223.

Sun, 06/18/2017 - 12:45
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Bone mesenchymal stem cells ameliorate ischemia/reperfusion-induced damage in renal epithelial cells via microRNA-223.

Stem Cell Res Ther. 2017 Jun 15;8(1):146

Authors: Yuan X, Wang X, Chen C, Zhou J, Han M

Abstract
BACKGROUND: Recent studies have indicated that microRNA-223 (miR-223) plays a role in the tissue-protective effect of mesenchymal stem cells (MSCs). NLR family-pyrin domain containing 3 (NLRP3) was reported to affect a renal ischemia/reperfusion (I/R) injury by exerting a direct effect on the renal tubular epithelium. Therefore, we investigated how miR-223 and NLRP3 might function in kidneys exposed to conditions of ischemia and subsequent reperfusion.
METHODS: Hypoxia/reoxygenation (H/R) murine renal tubular epithelial cells (RTECs) were cocultured with either MSCs or hypoxia-pretreated MSCs (htMSCs), after which the RTECs were examined for their viability and evidence of apoptosis. Next, miR-223 expression in the MSCs was downregulated to verify that MSCs protected RTECs via the transport of miR-223. Kidney I/R KM/NIH mouse models were created and used for in vivo studies.
RESULTS: The results showed that coculture with MSCs significantly increased the viability of RTECs and decreased their rates of apoptosis. The levels of hepatocyte growth factor (HGF), insulin-like growth factor-1 (IGF-1), transforming growth factor beta (TGF-β), and vascular endothelial growth factor (VEGF) in samples of coculture supernatants were higher than those in samples of non-coculture supernatants. A bioinformatics analysis revealed a targeting relationship between miR-223 and NLRP3. A dual luciferase assay showed that miR-223 inhibited NLRP3 expression. The htMSCs displayed a protective function associated with an upregulation of miR-223 as induced by Notch1 and the downregulation of NLRP3. Conversely, inhibition of miR-223 impeded the protective effect of MSCs. In the I/R mouse models, injection of either MSCs or htMSCs ameliorated the damage to kidney tissue, while suppression of miR-223 expression in MSCs reduced their protective effect on mouse kidneys.
CONCLUSIONS: Our results demonstrate that miR-223 and NLRP3 play important roles in the treatment of renal tissue injuries with transplanted MSCs.

PMID: 28619106 [PubMed - in process]

Renoprotective Effect of Angiotensin-Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers in Diabetic Patients with Proteinuria.

Fri, 06/16/2017 - 12:45

Renoprotective Effect of Angiotensin-Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers in Diabetic Patients with Proteinuria.

Kidney Blood Press Res. 2017 Jun 15;42(2):358-368

Authors: Hsu FY, Lin FJ, Ou HT, Huang SH, Wang CC

Abstract
BACKGROUND/AIMS: Limited evidence exists on the choice of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) in diabetic patients with nephropathy. We aim to assess the renal effectiveness and safety of these drugs among diabetic nephropathy patients.
METHODS: This retrospective cohort study was conducted with diabetic nephropathy patients who initiated ACEI or ARB monotherapy. The primary outcome was a composite of end stage of renal disease and renal transplantation, and the secondary outcome was all-cause mortality. The safety endpoint was hyperkalemia.
RESULTS: Three thousand seven hundred and thirty-nine ACEI users and 3,316 ARB users were identified. ARBs seemed to be inferior to ACEIs given their poorer renal outcome (HR 1.31; 95% CI, 1.15-1.50) and higher risk of hyperkalemia (HR 1.17; 95% CI, 1.04-1.32). Among the four ACEIs compared, captopril was an inferior treatment choice given its poorer renal outcomes (HR 1.42; 95% CI, 1.05-1.93) and higher mortality rate (HR 1.25; 95% CI, 1.01-1.55). Irbesartan appeared to be a poorer treatment choice among the three ARBs compared, given its inferior renal protective effect (HR 1.35; 95% CI, 1.03-1.78).
CONCLUSIONS: Our findings suggest ACEIs as a relatively more renoprotective and safer treatment as compared to ARBs. Captopril and irbesartan may be inferior to the other ACEIs and ARBs respectively.

PMID: 28618426 [PubMed - as supplied by publisher]

Stem cells: An emerging novel therapeutic for type-1 diabetes mellitus.

Fri, 06/16/2017 - 12:45

Stem cells: An emerging novel therapeutic for type-1 diabetes mellitus.

Diabetes Res Clin Pract. 2017 Apr 19;130:130-132

Authors: Thakkar UG, Vanikar AV, Trivedi HL

Abstract
Stem cell based strategies are therapeutically potent for treating type-1 diabetes mellitus owing to their intrinsic regenerative capacity and immunomodulatory properties to arrest autoimmune β-cell destruction, preserve residual β-cell mass, facilitate endogenous regeneration, ameliorate innate/ alloimmune graft rejection, restore β-cell-specific unresponsiveness in absence of chronic immunosuppression and to reverse hyperglycemia.

PMID: 28618324 [PubMed - as supplied by publisher]

Herpes simplex virus-2 transmission following solid organ transplantation: Donor-derived infection and transplantation from prior organ recipients.

Fri, 06/16/2017 - 12:45

Herpes simplex virus-2 transmission following solid organ transplantation: Donor-derived infection and transplantation from prior organ recipients.

Transpl Infect Dis. 2017 Jun 15;:

Authors: Macesic N, Abbott IJ, Kaye M, Druce J, Glanville AR, Gow PJ, Hughes PD, Korman TM, Mulley WR, O'Connell PJ, Opdam H, Paraskeva M, Pitman MC, Setyapranata S, Rawlinson WD, Johnson PDR

Abstract
BACKGROUND: Owing to limited availability of donor organs, previous solid organ transplant (SOT) recipients are increasingly considered as potential organ donors. We report donor-derived transmission of herpes simplex virus type-2 (HSV-2) to two clusters of SOT recipients with transmission from the original donor and an HSV-2-infected recipient who subsequently became a donor.
METHODS: We reviewed medical records of the donors and recipients in both clusters. Pre-transplant serology and virological features of HSV-2 were characterized. Genotyping of HSV-2 isolates to determine potential for donor transmission of HSV-2 through transplantation of organs from prior organ recipients was performed.
RESULTS: A kidney-pancreas recipient died day 9 post transplant. Following confirmation of brain death, the lungs and recently transplanted kidney were donated to two further recipients. The liver was not retrieved, but biopsy confirmed HSV-2 infection. Testing on the original donor showed negative HSV-2 polymerase chain reaction and HSV immunoglobulin (Ig)M, but positive HSV-2 IgG. The liver recipient from the original donor developed HSV-2 hepatitis and cutaneous infection that responded to treatment with intravenous acyclovir. In the second cluster, lung and kidney recipients both developed HSV-2 viremia that was successfully treated with antiviral therapy. Genotyping of all HSV-2-positive samples showed 100% sequence homology for three recipients.
CONCLUSIONS: Donor-derived HSV infection affected two clusters of recipients because of transplantation of organs from a prior organ recipient. HSV should be considered as a possible cause of illness in febrile SOT recipients in the immediate post-transplant period and may cause disseminated disease and re-infection in HSV-2-seropositive recipients. Testing of HSV serology and prophylaxis may be considered in SOT recipients not receiving cytomegalovirus prophylaxis. This article is protected by copyright. All rights reserved.

PMID: 28618165 [PubMed - as supplied by publisher]

Epidemiology of chronic kidney disease: think (at least) twice!

Fri, 06/16/2017 - 12:45

Epidemiology of chronic kidney disease: think (at least) twice!

Clin Kidney J. 2017 Jun;10(3):370-374

Authors: Delanaye P, Glassock RJ, De Broe ME

Abstract
The introduction of the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines has substantially contributed to the early detection of different stages of chronic kidney disease (CKD). Several recent studies from different parts of the world mention a CKD prevalence of between 8 and 13%. There are several reasons the CKD prevalence found in a study of a particular population is clearly overestimated. The structure of the population pyramid (young or older age) of the study sample may result in high or low CKD prevalence. The absence of using an isotope dilution mass spectrometry creatinine assay can be the source of high bias in CKD prevalence. In addition, using an arbitrary single threshold of estimated glomerular filtration rate (eGFR; <60 mL/min/1.73 m(2)) for classifying CKD leads to a substantial 'overdiagnosis' (false positives) in the elderly (>65 years of age), particularly in those without albuminuria (or proteinuria), haematuria or hypertension. It also results in a significant 'underdiagnosis' (false negatives) in younger individuals with an eGFR >60 mL/min/1.73 m(2) and below the third percentile for their age/gender category. The use of third percentile eGFR rates as a cut-off based on age/gender-specific reference values of eGFR allows the detection of these false positives and negatives. In the present article, we focus on an important and frequently omitted criterion in epidemiological studies: chronicity. Indeed, the two most important factors introducing a high number (up to 50%) of false positives are lack of confirming proteinuria and the absence of proof of chronicity of the eGFR found at first screening. There is an urgent need for quality studies of the prevalence of CKD using representative randomized samples of the population, applying the KDIGO guidelines correctly.

PMID: 28617483 [PubMed - in process]

The Frequency and Associated Factors for BK Virus Infection in a Center Performing Mainly Living Kidney Transplantations.

Fri, 06/16/2017 - 12:45

The Frequency and Associated Factors for BK Virus Infection in a Center Performing Mainly Living Kidney Transplantations.

Prog Transplant. 2017 Jun;27(2):152-159

Authors: Alagoz S, Kuskucu M, Gulcicek S, Yalin SF, Oruc M, Midilli K, Yılmaz E, Altiparmak MR, Seyahi N

Abstract
PURPOSE: BK virus (BKV) nephropathy has increasingly become an important cause of morbidity in renal transplant recipients. We evaluated the frequency and associated factors for BKV infection in a center performing mainly living donor transplantations over a long time period.
METHODS: One hundred consecutive renal transplant patients were included. Quarterly visits were planned to examine urine for decoy cells and to measure the BKV DNA in the blood and urine. Renal biopsy was performed in case of deteriorated allograft function. Serological examinations for BKV immunoglobulin G (IgG) were performed in donors.
RESULTS: Throughout the entire follow-up period, the rates of viruria, viremia, and the positivity of decoy cells were 12%, 6%, and 13%, respectively. The negative and positive predictive values of decoy cells were 93.1% and 69.2%, respectively, for viruria, and 99.2% and 45.5%, respectively, for viremia. Biopsy-proven BKV nephropathy was observed in 1 patient. The BKV IgG was positive in all living donors. Viruria and viremia were associated with deceased donor transplantation, acute rejection, and pulse steroid therapy. In addition, viremia was associated with antithymocyte globulin therapy and a short duration of the posttransplant period.
CONCLUSIONS: The frequency of BKV infection was lower in our transplant unit compared to previous reports. Reduced doses of immunosuppression seem to be the main factor that may explain the reduced frequency. However, an active screening strategy is still of importance for this patient group.

PMID: 28617169 [PubMed - in process]

Renalase Assessment With Regard to Kidney Function, Lipid Disturbances, and Endothelial Dysfunction Parameters in Stable Renal Transplant Recipients.

Fri, 06/16/2017 - 12:45

Renalase Assessment With Regard to Kidney Function, Lipid Disturbances, and Endothelial Dysfunction Parameters in Stable Renal Transplant Recipients.

Prog Transplant. 2017 Jun;27(2):125-130

Authors: Stojanovic D, Cvetkovic T, Stojanovic M, Stefanovic N, Velickovic-Radovanovic R, Zivkovic N

Abstract
BACKGROUND: Renal transplant dysfunction has been shown to be independent predictor for premature cardiovascular disease and mortality. Renalase, a flavoprotein secreted by several tissues, including the kidney, has been found to regulate sympathetic tone and blood pressure. The purpose of this secondary analysis was to explore relationships among parameters of endothelial dysfunction, lipids, glomerular filtration rate, and renalase in 2 groups: renal transplant patients with controlled hypertension and healthy volunteers.
METHODS: In the parent study, 73 renal transplant recipients and 32 age- and gender-matched controls were enrolled. A fasting sample for endothelial, lipid, and renalase values, along with other clinical parameters, was obtained.
RESULTS: We found statistically significant inverse correlation between renalase and estimated glomerular filtration rate ( r = -0.552, P < .001), positive correlation between renalase and creatinine ( r = 0.364, P = .003), total cholesterol ( r = 0.578, P < .001), low-density lipoprotein cholesterol ( r = 0.261, P = .046), and non-high-density lipoprotein cholesterol ( r = 0.327, P = .01). Renalase inversely correlated with hemoglobin ( r = -0.232, P = .032) and positively with white blood cells ( r = 0.233, P = .032). There was a significant difference in plasma renalase with regard to chronic kidney disease stages ( F = 13.346, P < .001) but did not correlate with C-reactive protein. Renalase did not correlate with any of parameters of endothelial dysfunction, C-reactive protein, neither with some demographic data (gender, age, time or type of transplantation, risk factors). There were no differences in renalase concentration with regard to antihypertensive therapy.
CONCLUSION: Renalase strongly and inversely correlated with kidney function, positively with creatinine and lipid disturbances. Due to that it is very likely that renalase levels are determined mostly by renal function.

PMID: 28617168 [PubMed - in process]

Patient-Reported Barriers to the Prekidney Transplant Evaluation in an At-Risk Population in the United States.

Fri, 06/16/2017 - 12:45

Patient-Reported Barriers to the Prekidney Transplant Evaluation in an At-Risk Population in the United States.

Prog Transplant. 2017 Jun;27(2):131-138

Authors: Lockwood MB, Saunders MR, Nass R, McGivern CL, Cunningham PN, Chon WJ, Josephson MA, Becker YT, Lee CS

Abstract
BACKGROUND: Despite our knowledge of barriers to the early stages of the transplant process, we have limited insight into patient-reported barriers to the prekidney transplant medical evaluation in populations largely at-risk for evaluation failure.
METHODS: One-hundred consecutive adults were enrolled at an urban, Midwestern transplant center. Demographic, clinical, and quality of life data were collected prior to patients visit with a transplant surgeon/nephrologist (evaluation begins). Patient-reported barriers to evaluation completion were collected using the Subjective Barriers Questionnaire 90-days after the initial medical evaluation appointment (evaluation ends), our center targeted goal for transplant work-up completion.
RESULTS: At 90 days, 40% of participants had not completed the transplant evaluation. Five barrier categories were created from the 85 responses to the Subjective Barriers Questionnaire. Patient-reported barriers included poor communication, physical health, socioeconomics, psychosocial influences, and access to care. In addition, determinants for successful evaluation completion included being of white race, higher income, free of dialysis, a lower comorbid burden, and reporting higher scores on the Kidney Disease Quality of Life subscale role-emotional.
CONCLUSION: Poor communication between patients and providers, and among providers, was the most prominent patient-reported barrier identified. Barriers were more prominent in marginalized groups such as ethnic minorities and people with low income. Understanding the prevalence of patient-reported barriers may aid in the development of patient-centered interventions to improve completion rates.

PMID: 28617167 [PubMed - in process]

Transplant Professionals' Perceptions of Long-Term Care Residents' Candidacy for Kidney Transplantation.

Fri, 06/16/2017 - 12:45

Transplant Professionals' Perceptions of Long-Term Care Residents' Candidacy for Kidney Transplantation.

Prog Transplant. 2017 Jun;27(2):146-151

Authors: Urbanski M, Browne T, Ghanta M, Constantinescu S, Gillespie A, Hammer H, Traino H

Abstract
CONTEXT: Given the aging end-stage renal disease (ESRD) population, kidney transplant (KTx) centers may experience an increase in referrals of patients living in long-term care (LTC) settings (eg, skilled nursing facilities, assisted living facilities, group homes, and boarding homes).
OBJECTIVE: To identify best practices among KTx professionals when considering individuals in LTC settings for transplantation.
DESIGN AND SETTING: A cross-sectional survey administered online to US transplant professionals via e-mail LISTSERVs and other professional networks.
PARTICIPANTS: One hundred twenty-six KTx professionals working in the United States.
MAIN OUTCOME MEASURES: The survey was composed of demographic questions and 6 hypothetical scenarios. These scenarios asked participants to assess transplant candidacy of patients with ESRD living in LTC settings based on the information provided in the scenario. Each scenario presented a different variable that necessitated LTC placement, including lack of social support, moderate intellectual disability, stable neurological condition, mild dementia, a psychiatric condition controlled on medications, and limited mobility.
RESULTS: The only scenario that elicited an overwhelmingly negative response was mild dementia with 73.9% of participants unwilling to consider such patients for KTx. By contrast, the proportion of KTx professionals reluctant to proceed with KTx in the remaining scenarios ranged between 40.0% and 50.6%.
CONCLUSIONS: This survey of a large number of KTx professionals suggests that there is presently no best practice consensus regarding offering KTx to patients living in LTC settings. Further research should include a broader range of KTx professionals and should also include a study of outcomes with KTx in this particular patient population.

PMID: 28617165 [PubMed - in process]

Rising Need for Health Education Among Renal Transplant Patients and Caregiving Competence in Care Providers.

Fri, 06/16/2017 - 12:45

Rising Need for Health Education Among Renal Transplant Patients and Caregiving Competence in Care Providers.

Prog Transplant. 2017 Jun;27(2):180-186

Authors: Xie J, Ming Y, Ding S, Wu X, Liu J, Liu L, Zhou J

Abstract
BACKGROUND: Health education positively affects the efficacy of self-management and should be carried out according to the status of patients' needs, knowledge, and the competence of the primary caregivers.
OBJECTIVES: This study was to investigate the needs of health education knowledge in transplant patients and the competence of the primary caregivers.
METHODS: This is a cross-sectional study using a convenient sampling approach. Self-report questionnaires were applied to 351 renal transplantation patients and their primary caregivers.
RESULTS: Three-hundred nine valid questionnaires were included in the analysis. The intensive care unit environment, stress coping strategies, the operation procedure, anesthesia and adverse reactions, and hand hygiene were the 5 most poorly understood aspects in health education. Stress coping strategies, at-home self-monitoring of health, pulmonary infection prevention, dietary needs, and anesthesia and other adverse reactions were the top 5 health education needs. Decision and self-efficacy were the weakest caregiving competence. Significant positive correlations were observed between health education knowledge level and caregiving competence in the primary caregivers. Marriage, education level, career, expense reimbursement, and residence significantly contributed to the health education demand questionnaire model, whereas gender, age, ethnic group, education level, career, and expense reimbursement significantly contributed to health education knowledge questionnaire model ( P < .05).
CONCLUSION: The renal transplant patients and their primary caregivers need health education on the intensive care unit environment, stress coping strategies, the operation procedure, and anesthesia and other adverse reactions. The primary caregivers need training in decision-making and self-efficacy.

PMID: 28617160 [PubMed - in process]

Ambulatory Care Coordination Issues With Dual Use Veteran Organ Transplant Recipients.

Fri, 06/16/2017 - 12:45

Ambulatory Care Coordination Issues With Dual Use Veteran Organ Transplant Recipients.

Prog Transplant. 2017 Jun;27(2):187-191

Authors: Thrall SA, Egede LE, Taber DJ

Abstract
The previous literature indicates that patients receiving ongoing care in both Veterans Affairs (VA) and non-VA setting (dual care) may have reduced health outcomes. The objective of this study was to assess the impact of dual care provided to a veteran solid organ transplant population. This was a retrospective cohort study of stable solid organ transplant recipients receiving care at both a Veterans Affairs Medical Center and transplant center. Forty-six veteran organ transplant recipients met inclusion criteria. At baseline, mean age at transplant was 57 ± 10 years; 93% were male, 61% received kidney transplants. Thirty-nine percent of patients did not receive immunosuppressant concentrations at the recommended intervals. The incidence of veterans that had at least 2 providers caring for the same comorbidity was 63% for hypertension, 58% for diabetes, and 27% for dyslipidemia. Approximately one-third of veterans had documentation of care provided by the other institutions (30%-37%), and 93% of patients had medication regimen discrepancies between health-care systems, with 52% of patients having at least 1 medication discrepancy involving an immunosuppressant. Most veteran solid organ transplant recipients receive care across multiple health-care systems, with significant care coordination issues leading to gaps and duplications in their management. Improved communication between health systems is imperative to optimize outcomes in dual use veterans such as organ transplant recipients.

PMID: 28617159 [PubMed - in process]

Vesicoureteral Reflux in Kidney Transplantation.

Fri, 06/16/2017 - 12:45

Vesicoureteral Reflux in Kidney Transplantation.

Prog Transplant. 2017 Jun;27(2):196-199

Authors: Molenaar NM, Minnee RC, Bemelman FJ, Idu MM

Abstract
BACKGROUND: Vesicoureteral reflux (VUR) is frequently found after transplantation, but its impact on graft function, urine tract infection, and graft loss remains uncertain. Therefore our objective was to evaluate the effects of VUR on the outcome of renal transplantation.
MATERIAL AND METHODS: We included 1008 adult renal transplant recipients of whom a 1-week posttransplant voiding cystourethrogram was available. Study end points included occurrence of bacteriuria, renal function, and graft survival.
RESULTS: In total, 106 (10.5%) of 1008 graft recipients had a diagnosis of VUR on voiding cystography. The incidence of bacteriuria was comparable in the reflux and nonreflux group (17% vs 17.4%, P = .91). There was no significant difference in renal function at 3 months and 1 year in patients with and without VUR. One- and 5-year graft survival in patients with VUR was 85.8% and 82.1% compared to 87.3% and 83.0% in patients without VUR ( P = .68 and P = .80).
CONCLUSION: Posttransplant VUR has no correlations with early bacteriuria, renal function, and graft survival.

PMID: 28617157 [PubMed - in process]

Blue after splenectomy.

Fri, 06/16/2017 - 12:45
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Blue after splenectomy.

Respir Med Case Rep. 2017;21:164-166

Authors: Ballachanda Subbaiah TC, Feldman JP

Abstract
INTRODUCTION: We present a 51 year old, African American, female who presented with persistent hypoxemia. She had been taking dapsone for many years for prophylaxis against Pneumocystic Jiroveci with no symptoms but eventually developed methemoglobinemia only after a splenectomy. From our literature review there are no documented cases that have demonstrated this relationship between dapsone, splenic function and methemoglobin and we hope to share our perplexing case and shed light on the interaction.
DESCRIPTION: Our patient has type 1 diabetes and underwent multiple pancreas transplants and an initial kidney transplant during her disease course. One year prior to her presentation she underwent a distal pancreatectomy and an incidental splenectomy during the same procedure. She had been taking dapsone for approximately 17 years due to her allergy to sulfamethoxazole/trimethoprim and her immunosuppressive regimen included tacrolimus, sirolimus, and low dose prednisone. She had presented for a routine, post-surgery follow up visit when she was diagnosed with hypoxemia. After an extensive but unsuccessful work up for persistent hypoxemia, she presented to our clinic for a second opinion. Repeat testing of the arterial blood gas in clinic showed a significant methemoglobin (MHb) level of 16.6 mg/dl.
DISCUSSION: Although methemoglobinemia is a well-known risk of dapsone exposure, we report a case that suggests that splenectomy can interact with dapsone to further increase the risk of methemobloginemia. We believe that our patient did not develop methemoglobinemia initially, despite being on dapsone for many years because her spleen was able to remove older more susceptible erythrocytes from the circulation leaving the more robust younger erythrocytes. With the splenectomy, the number of older erythrocytes in the peripheral circulation increased and resulted in an accumulation of MHb leading to the low oxygen saturations. Her dapsone was immediately stopped and she was started on vitamin C with a 3 day follow up revealing resolution of her methemoglobinemia and normal oxygen saturation on room air.

PMID: 28616377 [PubMed - in process]

Impact of seasonality on the dynamics of native Vitamin D repletion in long-term renal transplant patients.

Fri, 06/16/2017 - 12:45
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Impact of seasonality on the dynamics of native Vitamin D repletion in long-term renal transplant patients.

Clin Kidney J. 2017 Jun;10(3):411-418

Authors: Ziff OJ, Penny H, Frame S, Cronin A, Goldsmith D

Abstract
Background: Renal transplant recipients (RTRs) are often Vitamin D (VitD) depleted as a result of both chronic kidney disease and mandated sun avoidance behaviours. Repleting VitD may be warranted, but how, and for how long, is unknown, as is the impact of seasonality on the success of repletion. We investigated the impact of seasonality on VitD status following VitD repletion in a large cohort of stable, long-term RTRs. Methods: Serum 25-hydroxyvitamin D [25(OH)D] concentrations and bone biochemistry parameters were analysed from 102 VitD repletion courses in 98 RTRs that had undergone VitD repletion. Repletion was delivered over 6 months with either 240 000 IU colecalciferol if pre-repletion serum VitD was between 20 and 50 nmol/L, or with 360 000 IU if VitD was <20 nmol/L. Twelve months post-repletion 25(OH)D and parathyroid hormone (PTH) were available for 75 patients. Results: At baseline, 25(OH)D was 20.1 ± 1.0 nmol/L, increasing to 65.4 ± 1.8 nmol/L following repletion (+7.55 nmol/L/month, P < 0.0001). Twelve months post-repletion and after no further VitD administration, 25(OH)D fell to 35.4 ± 1.8 nmol/L (14.2 ± 0.7 ng/mL; -2.50 nmol/L/month, P < 0.0001). PTH followed the opposite trend with baseline, repletion-end and post-repletion values being 144.2 ± 12.0, 109.6 ± 7.5 and 129.2 ± 11.4 ng/L, respectively. VitD repletion during the summer was associated with significantly higher at repletion-end 25(OH)D compared with any other time of year [summer 80.9 ± 4.0, autumn 64.1 ± 3.0 (P = 0.002), winter 48.9 ± 3.0 (P <0.001), spring 63.8 ± 2.5 nmol/L (P <0.001)]. There was no hypercalcaemia during repletion and renal transplant function remained stable without any evidence of allograft rejection. Conclusions: VitD repletion can safely and effectively be achieved in the majority of chronic stable RTRs using a 6-month bolus intermediate-dose schedule. Winter repletion is associated with an inadequate response in 25(OH)D; however, all patients experience a post-repletion fall towards deficiency in the absence of maintenance supplementation, irrespective of the season of repletion.

PMID: 28616220 [PubMed - in process]

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