Significance of patient self‐monitoring for long‐term outcomes after lung transplantation

Kugler C, Gottlieb J, Dierich M, Haverich A, Strueber M, Welte T, Simon A. Significance of patient self‐monitoring for long‐term outcomes after lung transplantation.
Clin Transplant 2009 DOI: 10.1111/j.1399‐0012.2009.01197.x
© 2009 John Wiley & Sons A/S. Abstract: Background: Lung transplant (LTx) recipients’ adherence to regular self‐monitoring of lung function (SMLF) is important in maintaining health. This study investigated patients’ behavior based on electronic monitoring (EM) and compared these findings with self‐reported data. Methods: This single‐center study included 269 patients following LTx. Patients reported on adherence regarding SMLF, and data were compared to electronically stored measurements for the last three months prior to self‐reporting. Results: Non‐adherence was 59.4% based on EM for a total of 22 052 measurements performed. Main reported reasons for non‐adherence were forgetfulness (22%), lack of time (19%), and good self‐perception of health status (19%). Determinants for non‐adherence were patients constraining beliefs (p ≤ 0.0001), low perceived support from the transplant center (p ≤ 0.008), a history of infections (p ≤ 0.014) and rejections (p ≤ 0.043), and bronchiolitis obliterans (p ≤ 0.006). Multiple logistic regression revealed low‐perceived support from the transplant center (OR 3.22; 95% CI 1.32–7.83; p < 0.01), and lack of support from patient organizations (OR 2.19; 95% CI 1.02–4.72; p < 0.04) as independent predictors for non‐adherence. Conclusions: LTx recipients had some difficulties maintaining SMLF on a daily basis. Non‐adherence regarding lung function monitoring may provide a clinically relevant estimate of suspect cases for critical events impacting outcomes after LTx.     

Taking immunosuppressive medications effectively (TIMELink): a pilot randomized controlled trial in adult kidney transplant recipients

Russell C, Conn V, Ashbaugh C, Madsen R, Wakefield M, Webb A, Coffey D, Peace L. Taking immunosuppressive medications effectively (TIMELink): a pilot randomized controlled trial in adult kidney transplant recipients.
Clin Transplant 2011: 25: 864–870. © 2010 John Wiley & Sons A/S. Abstract: Background: Immunosuppressive medication non‐adherence is one of the most prevalent but preventable causes of poor outcomes in adult renal transplant recipients, yet there is a paucity of studies testing interventions in this area. Methods: Using a randomized controlled trial design, 30 adult renal transplant recipients were screened for medication non‐adherence using electronic monitoring. Fifteen non‐adherent participants were randomized to receive either a continuous self‐improvement intervention or attention control management. The six‐month continuous self‐improvement intervention involved the participant and clinical nurse specialist collaboratively identifying the person’s life routines, important people, and possible solutions to enhance medication taking. The participant then received individual monthly medication taking feedback delivered via a graphic printout of daily medication taking generated from electronic monitoring. Results: The mean medication adherence score for the continuous self‐improvement intervention group (n = 8) was statistically significantly higher than the attention control group’s (n = 5) mean medication adherence score (p = 0.03). The continuous self‐improvement intervention effect size (Cohen’s d) was large at 1.4. Participants’ perceptions of the intervention were highly favorable. Conclusions: The continuous self‐improvement intervention shows promise as an effective and feasible approach to improve medication adherence in adult renal transplant recipients. A fully‐powered study with a diverse sample is needed to confirm these preliminary findings.     

Factors related to immunosuppressant medication adherence in renal transplant recipients

Chisholm‐Burns M, Pinsky B, Parker G, Johnson P, Arcona S, Buzinec P, Chakravarti P, Good M, Cooper M. Factors related to immunosuppressant medication adherence in renal transplant recipients. Abstract: Non‐adherence to immunosuppressant medications (ISM) is a significant issue for transplant recipients. This study examines factors influencing ISM adherence in renal transplant recipients (RTRs). Patient‐reported data were collected through a cross‐sectional survey including use of ISMs, adherence behaviors, perceived adherence barriers, beliefs and attitudes toward ISMs, and patient life satisfaction. Logistic regression was conducted to examine how RTRs’ beliefs about use of ISMs, life satisfaction, and ISM adherence barriers were related to adherence. A total of 512 adult commercial insurance enrollees following renal transplantation were included in the analysis. One hundred and seventy‐seven RTRs were non‐adherent (34.5%); the most frequently cited reason was forgetfulness. RTRs aged 18–29 yr were more likely to be non‐adherent than recipients 46–64 yr old (p ≤ 0.001). Non‐adherent RTRs had greater adherence barriers than adherent RTRs (p < 0.001). Adherent RTRs believed their ISMs were more necessary than non‐adherent RTRs (p < 0.001), while non‐adherent RTRs had greater concerns about taking ISMs (p = 0.009) and believed they had less control over their lives than adherent RTRs (p < 0.001). Non‐adherent RTRs had lower life satisfaction (p < 0.001). Non‐adherence is significantly associated with patients’ beliefs about ISMs, perceived barriers, and lower life satisfaction. Strategies to increase ISM adherence are discussed.     

Medication understanding,non‐adherence,and clinical outcomes among adult kidney transplant recipients

We sought to evaluate the prevalence of medication understanding and non‐adherence of entire drug regimens among kidney transplantation (KT) recipients and to examine associations of these exposures with clinical outcomes. Structured, in‐person interviews were conducted with 99 adult KT recipients between 2011 and 2012 at two transplant centers in Chicago, IL; and Atlanta, GA. Nearly, one‐quarter (24%) of participants had limited literacy as measured by the Rapid Estimate of Adult Literacy in Medicine test; patients took a mean of 10 (SD=4) medications and 32% had a medication change within the last month. On average, patients knew what 91% of their medications were for (self‐report) and demonstrated proper dosing (via observed demonstration) for 83% of medications. Overall, 35% were non‐adherent based on either self‐report or tacrolimus level. In multivariable analyses, fewer months since transplant and limited literacy were associated with non‐adherence (all P<.05). Patients with minority race, a higher number of medications, and mild cognitive impairment had significantly lower treatment knowledge scores. Non‐white race and lower income were associated with higher rates of hospitalization within a year following the interview. The identification of factors that predispose KT recipients to medication misunderstanding, non‐adherence, and hospitalization could help target appropriate self‐care interventions.     

Non‐organ‐specific and anti‐endothelial antibodies in relation to CMV infection and acute rejection in renal transplant recipients

Costa C, Touscoz GA, Bergallo M, Terlizzi ME, Astegiano S, Sidoti F, Sinesi F, Segoloni GP, Cavallo R. Non‐organ‐specific and anti‐endothelial antibodies in relation to CMV infection and acute rejection in renal transplant recipients.
Clin Transplant 2010: 24: 488–492.
© 2009 John Wiley & Sons A/S. Abstract: The presence of non‐organ‐specific (NOSA) and anti‐endothelial antibodies (AECAs) and the onset of rejection in relation to cytomegalovirus (CMV) infection was investigated in 96 renal transplant recipients: 48 CMV pp65‐antigenemia‐negative (group 1) and 48 positive (group 2). The presence of autoantibodies (autoAbs) was evaluated before and following renal transplantation (first three months) by indirect immunofluoresce. Before transplantation, none of the patients was positive to AECAs, while eight (8.3%) were positive to NOSAs. Post‐transplantation, AECA were found in none of patients from group 1 vs. 15/48 (31.2%) from group 2 (p < 0.05); NOSAs were detected in 9/48 (18.8%) and 9/48 patients from group 1 and 2, respectively. An acute rejection was diagnosed in ten cases: six of interstitial type (antigenemia‐, and AECA‐negative; two NOSA‐positive); four of vascular type (all of them NOSA‐negative, 3/4 antigenemia‐, and AECA‐positive). CMV infection did not seem to be significantly associated with the appearance of NOSAs, while there was a significant correlation with the occurrence of AECAs. No significant correlation was found between acute rejection and the occurrence of NOSAs, while 75% of the cases of vascular rejection was associated to CMV infection and AECA‐positivity, suggesting the pathogenic role of CMV‐mediated endothelial damage.     

Muco‐cutaneous manifestations in 178 renal transplant recipients

Khosravi M, Golchai J, Mokhtari G. Muco‐cutaneous manifestations in 178 renal transplant recipients.
Clin Transplant 2011: 25: 395–400. © 2010 John Wiley & Sons A/S. Abstract: Introduction: Mucosal membrane and skin can be affected by immunosuppressive drug(s) and immunosuppression itself. The spectrum of muco‐cutaneous lesions can range from malignancy at one end to infection, iatrogenic lesions, and esthetic effects on the other end. Method: In Razi Hospital of Guilan University of Medical Sciences, a cross‐sectional study for the detection of muco‐cutaneous lesions in 178 renal transplant recipients (RTRs) was conducted from the years 2001 to 2006. Biopsy and skin scraping according to the type of skin lesions were performed. Results: A total of 31 RTRs (25%) had normal skin. Iatrogenic lesions were the most common (70%) followed by infectious lesions (57%), and miscellaneous skin lesions were exhibited by 26% of the patients. Among the iatrogenic skin lesions, gingival hyperplasia was the most common lesion (48%), followed by hypertrichosis and acne. Malignant lesions (biopsy proven) were recorded in seven patients (5%). Four patients were found to have Kaposi’s sarcoma, and three patients were identified with basal cell carcinoma. Conclusion: Our results showed that muco‐cutaneous lesions are crucial problems with RTRs. Attending physicians must pay close attention to skin care regularly and consider reduction of immunosuppression to a safe level, and patient must have self‐checkups.     

Evaluation of tools for annual capture of adherence to immunosuppressive medications after renal transplantation – a single‐centre open prospective trial

Annual assessment of adherence would strengthen long‐term outcome assessments from registry data. The objective of this study was to evaluate tools suitable for annual routine capture of adherence data in renal transplant recipients. A single‐centre open prospective trial included 295 renal transplant recipients on tacrolimus. Two‐thirds of the patients were included 4 weeks post‐transplant, randomized 1:1 to intensive or single‐point adherence assessment in the early phase and 1‐year post‐transplant. One‐third were included 1‐year post‐transplant during a cross‐sectional investigation. Adherence was assessed using multiple methods: The “Basel Assessment of Adherence to Immunosuppressive Medication Scale” (BAASIS^©) questionnaire was used to assess self‐reported adherence. The treating clinician scored patient′s adherence and tacrolimus trough‐concentration variability was calculated. In the analyses, the data from the different tools were dichotomized (adherent/nonadherent). The BAASIS^© overall response rate was over 80%. Intensive BAASIS^© assessment early after transplantation increased the chance of capturing a nonadherence event, but did not influence the 1‐year adherence prevalence. The adherence tools generally captured different populations. Combining the tools, the nonadherence prevalence at 1 year was 38%. The different tools identified to a large degree different patients as nonadherent. Combining these tools is feasible for annual capture of adherence status.     

Electronically measured adherence to immunosuppressive medications and kidney function after deceased donor kidney transplantation

Israni AK, Weng FL, Cen Y‐Y, Joffe M, Kamoun M, Feldman HI. Electronically measured adherence to immunosuppressive medications and kidney function after deceased donor kidney transplantation.
Clin Transplant 2011: 25: E124–E131. © 2010 John Wiley & Sons A/S. Abstract: Background:  Non‐adherence with immunosuppressive medications can result in allograft rejection and eventually allograft loss. Methods:  In a racially diverse population, we utilized microelectronic cap monitors to determine the association of adherence with a single immunosuppressive medication and kidney allograft outcomes post‐transplantation. This prospective cohort study enrolled 243 patients from eight transplant centers to provide adherence and kidney allograft outcomes data. To determine the association of adherence with change in estimated glomerular filtration rate (eGFR), we fit mixed effects models with the outcome being change in eGFR over time. We also fit Cox proportional hazards models to determine the association of adherence with time to persistent 25% and 50% decline in eGFR. Results:  The distribution of adherence post‐transplant was as follows: 164 (68%), 49 (20%), and 30 (12%) had >85–100%, 50–85%, and <50% adherence, respectively. Seventy‐nine (33%) and 36 (15%) of the subjects experienced a persistent 25% decline in eGFR or allograft loss and 50% decline in eGFR or allograft loss during follow‐up. Adherence was not associated with acute rejection or 25% decline or 50% decline in eGFR. In the adjusted and unadjusted model, adherence and black race were not associated with change in eGFR over time. Conclusions:  Non‐adherence with a single immunosuppressive medication was not associated with kidney allograft outcomes.     

Steroid minimization for sirolimus‐treated renal transplant recipients

Matas AJ, Granger D, Kaufman DB, Sarwal MM, Ferguson RM, Woodle ES, Gill JS. Steroid minimization for sirolimus‐treated renal transplant recipients.
Clin Transplant 2011: 25: 457–467. © 2010 John Wiley & Sons A/S. Abstract: Steroids are associated with a myriad of post‐transplant side effects. Therefore, as new immunosuppressive drugs have been developed, attempts have been made to minimize steroid exposure. Sirolimus (SRL) has been demonstrated to have efficacy in early and late post‐transplant immunosuppression. Accordingly, numerous trials have studied steroid minimization (early and late post‐transplant) in the context of SRL‐containing protocols (either with or without a calcineurin inhibitor). We herein review these trials and show that recent studies have determined that both late steroid withdrawal and early rapid discontinuation can be successful with SRL immunosuppression.     

Diagnostic Accuracy of Measurement Methods to Assess Non-Adherence to Immunosuppressive Drugs in Kidney Transplant Recipients

Valid assessment of immunosuppressive therapy non-adherence (NAH) is vital: NAH is associated with negative transplantation outcomes. We studied the diagnostic accuracy of assay, patient self-reports and clinicians' collateral reports and composite adherence scores using electronic monitoring (EM) as a reference standard.
This cross-sectional study included a convenience sample of 249 adult kidney transplant recipients (Ktx) (female: 43.4%; mean age 53.6 [SD: 12.7], median 7 years [IQR: 9 years] post-Ktx). NAH was assessed using EM over 3 months (i.e. reference standard), assays of cyclosporine, tacrolimus, mycophenolat-mofetil, patients' self-reports and clinicians' collateral reports. The constructed composite adherence score included assay, self-reports and collateral reports.
NAH's prevalence across the measurement methods was EM: 17.3%; assay: 33% (cyclosporine: 25.8%; tacrolimus: 35.1%; mycophenolat-mofetil: 40.2%); self-report: 12.4%; collateral reports: 24.9% and composite adherence score: 38.9%, respectively. The composite adherence score and collateral reports showed the highest and lowest sensitivities to NAH (72.1% and 15.8%, respectively). Specificity was highest for collateral reports of at least three clinicians (93.1%). Likelihood ratio of a positive test was 2.74 for composite adherence score.
No measures showed high sensitivity alongside high specificity. Combining measures increased diagnostic accuracy, indicating the relevance of combined measures for clinical and research purposes.     

Prospective study of polyomavirus BK replication and nephropathy in renal transplant recipients in China: a single‐center analysis of incidence,reduction in immunosuppression and clinical course

Huang G, Chen L‐Z, Qiu J, Wang C‐X, Fei J‐G, Deng S‐X, Li J, Chen G‐D, Zhang L, Fu Q, Zeng W‐T, Zhao D‐Q. Prospective study of polyomavirus BK replication and nephropathy in renal transplant recipients in China: a single‐center analysis of incidence, reduction in immunosuppression and clinical course.
Clin Transplant 2009 DOI: 10.1111/j.1399‐0012.2009.01141.x
© 2009 John Wiley & Sons A/S. Abstract: Background: BK virus (BKV)‐associated nephropathy (BKVAN) in renal transplant recipients is an important cause of renal transplant dysfunction. Our aim was to determine the kinetics of BKV load within one yr after kidney transplantation under the impact of intensive monitoring and reduction in maintenance immunosuppression, the incidence of BKVAN, and the outcome of BKVAN treatment. Methods: Urine and peripheral blood (PB) were taken from 90 renal transplant recipients for BKV cytological testing and real‐time PCR for BKV DNA at one, three, six, nine, and 12 months after transplantation and treatment. Graft biopsies and urinary sediments of recipients with BKVAN were taken to monitor viral particles by conventional transmission electron microscopy (TEM). Results: By one post‐transplant year, urinary decoy cells (median, 8/10 HPF), BKV viruria (median, 2.60 × 10⁵ copies/mL), viremia (median, 9.65 × 10³ copies/mL ) , and BKVAN occurred in 42.2%, 45.6%, 22.2%, and 5.6% of patients, respectively. The incidence of BK infection was lower in patients who received cyclosporine A (CsA) (28.9%) compared to tacrolimus (FK506) (57.7%) (p = 0.007). An increased hazard of BK infection was associated with the use of FK506 (HR 2.6, p = 0.009) relative to CsA. After reduction in immunosuppression, viremia resolved in 95%, without increased acute rejection, allograft dysfunction, or graft loss. BKVAN was diagnosed in five patients (5.6%). The treatment of immunosuppression reduction was effective (i.e., decreased the viral load and number of decoy cells, and improved graft function) in our five patients with BKVAN. Quantitative count of decoy cells (e.g., >10 per 10 HPF) as a marker of viremia and BKVAN had increased positive predictive values of 85.7% and 57.1%, respectively. Conclusions: Choice of FK506 as immunosuppressive agent is an independent risk factor affecting BKV infection. Monitoring and pre‐emptive of immunosuppression reduction were associated with resolution of viremia and showed effective in BKVAN recipients at the early stage without acute rejection or graft loss. Quantitative count of urine cytology is a very convenient, useful, and sensitive method for evaluating BKV infection in renal transplant recipients.     

Clinical validation of a novel enzyme‐linked immunosorbent spot assay‐based in vitro diagnostic assay to monitor cytomegalovirus‐specific cell‐mediated immunity in kidney transplant recipients: a multicenter,longitudinal, prospective,observational study

Impaired cytomegalovirus (CMV)‐specific cell‐mediated immunity (CMV‐CMI) is a major cause of CMV reactivation and associated complications in solid‐organ transplantation. Reliably assessing CMV‐CMI is desirable to individually adjust antiviral and immunosuppressive therapy. This study aimed to evaluate the suitability of T‐Track^® CMV, a novel IFN‐γ ELISpot assay based on the stimulation of peripheral blood mononuclear cells with pp65 and IE‐I CMV proteins, to monitor CMV‐CMI following kidney transplantation. A prospective longitudinal multicenter study was conducted in 86 intermediate‐risk renal transplant recipients. CMV‐CMI, CMV viral load, and clinical complications were monitored over 6 months post‐transplantation. Ninety‐five percent and 88–92% ELISpot assays were positive pre‐ and post‐transplantation, respectively. CMV‐specific response was reduced following immunosuppressive treatment and increased in patients with graft rejection, indicating the ability of the ELISpot assay to monitor patients' immunosuppressive state. Interestingly, median pp65‐specific response was ninefold higher in patients with self‐clearing viral load compared to antivirally treated patients prior to first viral load detection (P < 0.001), suggesting that reactivity to pp65 represents a potential immunocompetence marker. Altogether, T‐Track^® CMV is a highly sensitive IFN‐γ ELISpot assay, suitable for the immunomonitoring of CMV‐seropositive renal transplant recipients, and with a potential use for the risk assessment of CMV‐related clinical complications (ClinicalTrials.gov Identifier: NCT02083042).     

Immune functional assay for immunosuppressive management in post‐transplant malignancy

Uemura T, Riley TR, Khan A, Hollenbeak C, Schreibman I, Ghahramani N, Reeves B, Domen RE, Zander DS, Kadry Z. Immune functional assay for immunosuppressive management in post‐transplant malignancy.
Clin Transplant 2011: 25: E32–E37. © 2010 John Wiley & Sons A/S. Abstract: Immunosuppression management in post‐transplant malignancy is challenging because of a lack of objective immunologic assessment tools. The ImmuKnow assay measures the ATP level from CD4 T cells, quantifying cell‐mediated immunity and providing an insight into the immune status of transplant recipients. Its potential use in patients with post‐transplant de novo malignancy was evaluated. Thirteen adult transplant patients with de novo malignancy were divided into survivors (n = 9) and non‐survivors (n = 4) after malignancy treatment. Tacrolimus and the ImmuKnow levels were monitored before, during, and after malignancy treatment. The ImmuKnow level in non‐survivors group was significantly lower before and after malignancy treatment compared to survivors group (p = 0.013 and 0.0014 respectively). In survivor group, the ImmuKnow level was significantly decreased during malignancy treatment (p = 0.019) but recovered to the initial level after the treatment. However, in non‐survivor group, the ImmuKnow level remained suppressed throughout the observed period despite a reduction in immunosuppressive drug levels. The ImmuKnow assay can be an objective means evaluating immune status of patients with de novo malignancy. The ImmuKnow assay can express the degree of immune suppression induced by chemotherapeutic or radiation therapy and may be a useful tool in optimizing the timing of re‐introduction of immunosuppression after malignancy treatment.     

Describing the evolution of medication nonadherence from pretransplant until 3 years post‐transplant and determining pretransplant medication nonadherence as risk factor for post‐transplant nonadherence to immunosuppressives: The Swiss Transplant Cohort Study

Although medication nonadherence (MNA) is a major risk factor for poor outcomes, the evolution of MNA from pre‐ to 3 years post‐transplant among the four major organ transplant groups remains unknown. Therefore, this study described this evolution and investigated whether pretransplant MNA predicts post‐transplant immunosuppressive medication nonadherence (IMNA). Adult participants (single transplant, pretransplant and ≤1 post‐transplant assessment, using medications pretransplant) in the Swiss Transplant Cohort Study (a prospective nation‐wide cohort study) were included. Nonadherence, defined as any deviation from dosing schedule, was assessed using two self‐report questions pretransplant and at 6, 12, 24 and 36 months post‐transplant. Nonadherence patterns were modelled using generalized estimating equations. The sample included 1505 patients (average age: 52.5 years (SD: 13.1); 36.3% females; 924 renal, 274 liver, 181 lung, 126 heart). The magnitude and variability of self‐reported MNA decreased significantly from pretransplant to 6 months post‐transplant (OR = 0.21; 95% CI: 0.16–0.27). Post‐transplant IMNA increased continuously from 6 months to 3 years post‐transplant (OR = 2.75; 95% CI: 1.97–3.85). Pretransplant MNA was associated with threefold higher odds of post‐transplant IMNA (OR = 3.10; 95% CI: 2.29–4.21). As pretransplant MNA predicted post‐transplant IMNA and a continuous increase in post‐transplant IMNA was observed, early adherence‐supporting interventions are indispensible.     

Interleukin‐2 receptor antibody does not reduce rejection risk in low immunological risk or tacrolimus‐treated intermediate immunological risk renal transplant recipients

Aim: The use of interleukin‐2 receptor antibody (IL‐2Ra) induction has been associated with reduced rejection rates in renal transplant recipients. However, the effect of IL‐2Ra induction on graft and patient outcomes in renal transplant recipients with differing immunological risk remains unclear. Methods: Using Australia and New Zealand Dialysis and Transplant Registry, renal transplant recipients in Australia between 1995 and 2005 were included. Recipients were stratified into low immunological risk (primary grafts with ≤2 human leucocyte antigen (HLA)‐mismatches and panel‐reactive antibody (PRA) < 10%) or intermediate immunological risk (subsequent grafts or >2 HLA‐mismatches or PRA > 25%) recipients. Recipients receiving T‐cell depletive induction therapy or steroid and/or calcineurin‐free inhibitor regimens were excluded. Outcomes analysed included the presence of rejection at 6 months, estimated glomerular filtration rate at 1 and 5 years, graft and patient survival. Results: 218 of 1220 (18%) low‐risk and 883 of 3204 (28%) intermediate‐risk recipients received IL‐2Ra. In intermediate‐risk recipients, IL‐2Ra induction was associated with a 26% reduction in the incidence of acute rejection; but this benefit was restricted only to recipients initiated on cyclosporine‐based immunosuppressive regimens. In contrast, the use of IL‐2Ra in low‐risk recipients was not associated with reduced rejection risk. There was no association between IL‐2Ra induction and other graft or patient outcomes in both low‐ and intermediate‐risk recipients. Conclusion: This registry analysis suggests that IL‐2Ra induction may be associated with a reduction in rejection risk in cyclosporine‐treated intermediate immunological risk recipients, but not in low‐risk renal transplant recipients.     

Outcomes of renal transplantation in recipients with Wegener’s granulomatosis

Shen J, Gill J, Shangguan M, Sampaio MS., Bunnapradist S. Outcomes of renal transplantation in recipients with Wegener’s granulomatosis.
Clin Transplant 2011: 25: 380–387. © 2010 John Wiley & Sons A/S. Abstract: Wegener’s granulomatosis (WG) is the leading cause of rapidly progressive glomerulonephritis‐induced end‐stage renal disease (ESRD). In this study, we compared transplant outcomes between recipients with ESRD caused by WG to recipients with ESRD secondary to other causes. Using OPTN/UNOS data from 1996 to 2007, 919 recipients with WG were identified. Post‐transplant outcomes included rates of delayed graft function, acute rejection within one‐yr post‐transplant, overall and death‐censored graft survival, and patient survival and were compared between recipients with ESRD secondary to WG versus ESRD from other causes. Recipients with ESRD because of WG had superior unadjusted and adjusted rates of graft loss, patient death, and functional graft loss (adjusted hazard ratio [HR] 0.711, 0.631, and 0.625 respectively, p < 0.001). When we compared the WG cohort to a non‐WG, non‐diabetic population, the HR for graft loss was still significant, but patient death and death‐censored graft loss were not. Subgroup analysis of recipients aged over 60 confirmed that WG recipients had better unadjusted outcomes. This study supports the notion that renal transplantation is an effective treatment option for patients with ESRD secondary to WG. They fare similarly, if not better, than other patients.     

Obstetric and long‐term kidney outcomes in renal transplant recipients: a 40‐yr single‐center study

Female renal transplant recipients of childbearing age may ask what the outcomes are for pregnancy and whether pregnancy will affect graft function. We analyzed obstetric and transplant outcomes among renal transplant recipients in our center who have been pregnant between 1973 and 2013. A case?cohort study was performed identifying 83 pairs of pregnant and non‐pregnant controls matched for sex, age, transplant vintage, and creatinine. There were 138 pregnancies reported from 89 renal transplant recipients. There were live births in 74% of pregnancies with high prevalence of prematurity (61%), low birth weight (52%), and pre‐eclampsia (14%). Lower eGFR (OR 0.98; p = 0.05) and higher uPCR (OR 1.86; p = 0.02) at conception were independent predictors for poor composite obstetric outcome. Lower eGFR (OR 0.98; p = 0.04), higher uPCR (OR 1.50; p = 0.04), and live organ donation (OR 0.35; p = 0.02) were predictors of ≥20% loss of eGFR between immediately pre‐pregnancy and one yr after delivery. There was no difference in eGFR at one, five, and 10 yr in pregnant women compared with non‐pregnant controls and a pregnancy was not associated with poorer 10‐yr transplant or 20‐yr patient survival. Despite high rates of obstetric complications, most women had successful pregnancies with good long‐term transplant function.     

Ten‐yr results of the trans‐Atlantic kidney transplant airlift between the Dutch Caribbean and the Netherlands

Minnee RC, Lardy N, Ajubi N, Idu MM, Kock RV, Legemate DA, van Donselaar‐van der Pant KAMI, Bemelman FJ. Ten‐yr results of the trans‐Atlantic kidney transplant airlift between the Dutch Caribbean and the Netherlands.
Clin Transplant 2011: 25: 302–307. © 2010 John Wiley & Sons A/S. Abstract: The prevalence of end‐stage renal failure in Curaçao (Dutch Caribbean) is one of the highest in the world. In 1998, the St. Elisabeth Hospital started a unique trans‐Atlantic collaboration with the Academic Medical Center in Amsterdam, the Netherlands, and the Eurotransplant Foundation. The partnership aimed to achieve a structured transplantation program for patients in the Dutch Caribbean, who otherwise would need lifelong dialysis. This study is an analysis of the 10‐yr transplantation results of this trans‐Atlantic program. In 41 consecutive transplantations performed between January 1998 and April 2007, one‐yr graft survival and complication rates were retrospectively studied. Twenty‐four men and 17 women with a median age of 54 were transplanted. The median dialysis period prior to transplantation was 6.8 yr. The one‐yr graft survival rate was 69% (95% confidence interval: 52–80%). Initially 28 grafts functioned (68%); four grafts showed primary non‐function (10%) and delayed graft function developed in nine patients (22%). Ten recipients had 16 post‐operative complications. Our trans‐Atlantic program affords patients with end‐stage renal failure, who otherwise would need lifelong dialysis, a chance to be transplanted.     

Evaluation of a hand-held, computer-based intervention to promote early self-care behaviors after lung transplant

Abstract: Background: Lung transplant recipients are expected to perform self‐care behaviors to maximize transplant‐related health outcomes. Despite high non‐adherence rates in performing these self‐care behaviors, and the dire clinical consequences of such non‐adherence, interventions are lacking. Pocket Personal Assistant for Tracking Health (Pocket PATH) is a hand‐held device developed for patients to record health data, review data trends, and report condition changes to the transplant team. Methods: A pilot trial was conducted to compare self‐care agency, self‐care behaviors, and health‐related quality of life (HRQOL) between recipients randomized to use Pocket PATH (n = 15) vs. standard care (n = 15) for the first two months following hospital discharge after lung transplantation. Results: Baseline characteristics were equivalent across groups. Patients in the Pocket PATH group showed significantly higher ratings of self‐care agency, performed self‐care behaviors at significantly higher rates, and reported significantly better HRQOL than standard care controls. Conclusion: Pocket PATH is more efficacious than standard care in promoting early self‐care agency, self‐care behaviors, and HRQOL in lung recipients. A large‐scale randomized controlled trial is needed to test the impact of Pocket PATH on long‐term self‐care behaviors.