Cyclosporine-induced transient renal hypoperfusion in adolescent transplant recipients

We investigated the acute hemodynamic effect of a single oral dose of cyclosporine A (CsA) given as part of the immunosuppressive schedule in six adolescents with renal transplants. Renal plasma flow (RPF) and glomerular filtration rate (GFR) were determined by continuous infusion of inulin and amino-hippuric acid for 12 h. A fall in both GFR and RPF was observed 4–6 h after peak plasma CsA levels. No significant correlation was found with CsA dosage or any pharmacokinetic parameters. This study demonstrates that CsA also has a vasoconstrictory effect in adolescent recipients; this could be one of the causes of its nephrotoxicity.     

Compliance with cyclosporine in adolescent renal transplant recipients

  Inadequate compliance with prescribed medication regimens in children is complex and poorly understood. We measured the extent and pattern of noncompliance with cyclosporine in our adolescent renal transplant population and attempted to determine factors associated with poor compliance. After informed consent, each patient was provided cyclosporine capsules in a medication bottle equipped with an electronic monitoring device (MEMS-4) in the lid. Of the 24 patients eligible, 19 patients (8 female, 11 male) completed the study. Four (21%) patients took less than 80% of the prescribed cyclosporine doses. Five (26%) patients took drug holidays involving ≥3 consecutive doses. There was a trend towards improved compliance with the evening dose (88.5% vs. 93.4%, P = 0.09) and a downward trend in compliance over the course of the study (P = 0.17). None of the variables tested were found to be associated with noncompliance. Experienced physicians and nurses were able to identify 2 of the 4 individuals who were identified by MEMS as noncompliant. Additionally, 2 of the 4 noncompliant patients demonstrated low cyclosporine trough levels (<50 ng/ml). Noncompliance with cyclosporine regimens occurs commonly in adolescent renal transplant recipients. Unexpectedly low cyclosporine levels are strongly suggestive of noncompliance, whereas other variables, including prediction by physicians and nurses intimately involved in the care, were not reflective of noncompliance. Received October 19, 1996; received in revised form February 18, 1997; accepted March 18, 1997     

Glucocorticoid-induced osteopenia in adolescent heart transplant recipients.

BACKGROUND: Glucocorticoid-induced cushingoid symptoms, including osteopenia and osteoporosis are well-documented in adult heart transplant recipients (HTR). Bone mineral density (BMD) of the axial skeleton is diminished by 10% to 20% within 60 days after transplantation (Tx) and most adult HTR fulfill World Health Organization criteria for osteoporosis (BMD > 2.5 SD below norm). At present, we do not know whether glucocorticoids have similar deleterious effects in adolescent HTR. METHODS: To determine the consequences of glucocorticoid immunosuppression on regional bone mineral density (BMD) and biochemical markers of bone metabolism in adolescent HTR, we studied 19 patients (aged 16 +/- 3) at 19 months (group mean) after Tx. We measured BMD (hydroxyapatite g/cm(2)) of the total body, lumbar spine, and pelvis using dual-energy X-ray absorptiometry (Lunar). Serum levels of bone-specific alkaline phosphatase and pyridinoline cross-links were determined by enzyme immunoassay in serum kits. RESULTS: The BMD of the lumbar spine (-12%), femur neck (-13%), femur trochanter (-12%), and ward's triangle (-16%) were significantly (p < 0.05) lower in adolescent HTR than age- and gender-matched norms. Serum levels of alkaline phosphatase (29 +/- 6 vs 22 +/- 3 U/liter) and pyridinoline cross-links (5.3 +/- 1.1 vs 3.8 +/- 0.7 mmol/liter) were significantly (p < 0.05) elevated in adolescent HTR, compared with age- and gender-matched controls studied in our laboratory. CONCLUSIONS: Our cross-sectional results demonstrate that BMD of the axial skeleton in adolescent HTR is significantly lower (-10% to 20%) than age-matched norms and that serum biochemical markers of bone metabolism are significantly elevated, suggesting accelerated bone turnover.     

Further exploration: maturity and adherence in adolescent and young adult heart transplant recipients

CONTEXT: Pediatric transplant clinicians note high rates of nonadherence with medications, appointment keeping, and laboratory tests and high rates of engagement in high-risk behaviors among older adolescents and young adult recipients. The caregivers also report symptoms of identity confusion, social immaturity, and failure to appreciate consequences of risky behavior among recipients. OBJECTIVE: To build on an earlier study that identified developmental characteristics that distinguish poor from good adherers. DESIGN: Qualitative methods were used to explore key themes identified in the first study with heart transplant recipients and their significant others. RESULTS: This research confirmed the themes of developmental maturity suggested by the first study: good adherers were able to integrate the transplant into sense of self, become independent adults, and achieve normalcy; poor adherers continued to "push away" the transplant experience and worried that they would never be normal. The good adherers, their parents, and friends had views of relationships that were congruent, acknowledging difficulties, discussing them, and moving toward mutual satisfaction. The poor adherers, their parents, and friends expressed incongruent views of the relationships, avoiding discussion of problems and idealizing relationships. DISCUSSION: Strategies for clinicians, family, and friends to increase maturity and independence among older adolescent and young adult heart transplant recipients are described.     

Interventional valve surgery: building a team and working together

Transcatheter aortic valve implantation (TAVI) is a new modality that may change the therapeutic landscape in the management of aortic valve stenosis. Despite the excellent results of surgical aortic valve replacement, TAVI has the potential to revolutionize the treatment of elderly and high-risk patients with aortic stenosis. It therefore constitutes a new reality that cardiac surgeons have to acknowledge. As TAVI indications and techniques become better defined, the importance of a team approach to the implementation and performance of TAVI is becoming increasingly evident. The surgeon has a crucial role to play in the introduction, development, and sustainability of TAVI at any institution. In this article, we discuss the procedural technique involved in TAVI, as well as the cardiologist and heart surgeon individualities and team dynamics. We make a case for judicious team-based adoption of TAVI technologies, considering that evidence-based and health economics data are not yet available. We also illustrate how a team approach may lead to improved outcomes, better patient and institutional acceptance, and a better definition of the therapeutic niche of TAVI modalities, amid the excellent results of conventional aortic valve replacement surgery.     

Use of nurse practitioners in pediatric kidney transplant: a model for providing comprehensive care to children and families

It is well documented that kidney transplantation is the treatment of choice for children with end-stage renal disease. Pediatric kidney transplant patients are a complex population because of their need for lifelong immunosuppression, potential for delayed growth and development, and increased risk of heart disease and cancer. Although many large pediatric kidney transplant programs use nurse practitioners, the role of the nurse practitioner is still emerging in relation to the transplant coordinator role. This article describes the practice of pediatric nurse practitioners caring for children who require a kidney transplant and why nurse practitioners are ideal for providing comprehensive care to this population. Transplant programs are regulated by the United Network for Organ Sharing and the Centers for Medicare and Medicaid Services. Both organizations require transplant programs to designate a transplant coordinator with the primary responsibility of coordinating clinical aspects of transplant care. Incorporating transplant coordinator activities into the role of the pediatric nurse practitioner is discussed as a model for providing care throughout the process of kidney transplantation. Transplant pediatric nurse practitioners are in a unique position to expand the care for pediatric kidney transplant patients by assuming the role of clinician, educator, administrator, and coordinator.     

伤口造口专科护士对开业护士的认知及态度调查

目的 了解伤口造口专科护士对开业护士认知及态度现状,探讨影响其认知的因素。方法 选取169名伤口造口专科护士作为研究对象,采用自行设计的伤口造口专科护士对开业护士认知及态度问卷进行在线调查。结果 伤口造口专科护士对开业护士认知得分为（67.03±14.10）分,多元线性回归分析显示文化程度和是否听说过开业护士是认知的影响因素;95.27%的伤口造口专科护士愿意成为开业护士;认为成为开业护士的最低学历、最低职称、最低工作年限要求分别是本科、中级、5～10年;52.07%认为国家政策导向是影响我国开业护士发展的首要因素;工作的开展急于需要完善相关法律法规、建立规范的开业护士准入制度、健全执业体系、形成中国特色的培养方案。结论 伤口造口专科护士对开业护士的态度积极,但认知有待提高,有必要提前进行相关知识渗透,及时出台政策法规,建立规范化准入制度、培养与执业体系是发展开业护士的有力保障。     

The dynamics of kidney donation: viewpoints from the donor, the recipients, and the transplant team

Living kidney transplantation has become increasingly widespread to reduce organ shortage. Very few studies have prospectively investigated the donor's long-term risks. Living donation is a complex medical decision in which different actors are involved. This therapeutic option needs educational programs for potential donors, recipients, and transplant professionals to make them aware of the possible risks and benefits. It is important to fully exploit living-donor kidney transplantation.     

Lung cancer in transplant recipients: a single-institution experience

HYPOTHESIS: That aggressive surgical treatment of lung cancer (LC) is justified by stage-based outcome in immunosuppressed solid organ transplant recipients. DESIGN: Case series. SETTING: University hospital. PATIENTS: Lung cancer developed in 15 patients (0.28%) among a solid organ transplant recipient population of 5400 accrued at our institution over a 25-year period. MAIN OUTCOME MEASURES: Smoking prevalence, subtypes and stages of LC represented, operative morbidity, and survival. RESULTS: The mean time from transplantation to the diagnosis of LC was 76 months (range, 9-192 months). Eight patients received kidneys; 3, lungs; and 4, hearts. Only 11 patients (73%) had a smoking history (mean, 66 pack-years). The following carcinomas developed in our patient population: adenocarcinoma, 6 patients; squamous cell, 5; large cell undifferentiated, 2; bronchoalveolar, 1; and small cell, 1. Eight patients (53%) presented with inoperable stage IIIB or IV disease. The remaining patients presented in stages IA (n = 2), IB (n = 1), IIB (n = 2), and IIIA (n = 2); all underwent resection. No major postoperative complications occurred. All patients with stage IIIB or greater disease with or without treatment died quickly (mean survival, 1.4 months; range, 0.33-3.0 months). All patients with stage IIB or less remain alive a mean of 37 months after resection. Patients with stage IIIA survived only a mean of 6.0 months despite resection. CONCLUSIONS: Regarding LCs in transplant recipients compared with LCs in the nontransplant population, we find that (1) there is an increased incidence among nonsmokers; (2) death occurs rapidly in unresected patients; (3) resection carries a low morbidity rate; and (4) resection seems to offer a high chance of cure in those with cancers staged IIB or less.     

Nephrology nurse practitioners in a collaborative care model

The use of nurse practitioners in the primary care setting is increasingly common. However, little information is available on their use in specialty care areas. This is especially true in nephrology, in which end-stage renal disease (ESRD) lends itself well to this type of practice. We describe our experience with a university-based collaborative care model for ESRD with nurse practitioners in nephrology. Our experience shows that nephrology nurse practitioners have a significant impact on extending the quality and quantity of patient care provided by the nephrologist. They facilitate a holistic patient-friendly approach, and, as an integral part of the collaborative model, there is an associated significant decrease in patient mortality relative to standard comparators. Nurse practitioners provide a large amount of care for ESRD patients in a relatively independent fashion but under the supervision and with the collaborative interaction of nephrologists. Patient satisfaction, approval, respect, and trust for the nurse practitioners are exceptional. The use of nephrology nurse practitioners provides the potential for augmenting patient care, satisfaction, and access to care. It provides an avenue for potential cost reduction in nephrology while maintaining quality of care. It further provides a partial solution to the anticipated shortage of nephrologists in the twenty-first century.     

Immunological monitoring as a guide to the management of transplant recipients.

Immunological monitoring assays are of current value in the management of transplant recipients. These assays allow the pre-transplant quantitation of both donor-recipient histocompatibility and recipient "responder status." In addition, these assays allow the individualization of immunosuppression, permitting a more uniform and effective immunosuppression in the difficult early post-transplant period. Individualized modulation of recipient immune reactivity avoids the documented pitfalls of conventional stereotyped suppression and permits better abrogation of acute rejection responses and lesser rates of serious infections consequent to excessive immune suppression. Immunological monitoring of long-surviving recipients permits early detection of immune reactivity which often culminates in clinical chronic rejection, as well as permits the quantitation of immune facilitory mechanisms (reduced capability to generate anti-donor cytotoxic T cells and/or cellular suppressor mechanisms) that indicate an immune milieu conductive to long-term graft survival. The primary limitations to the more widespread use of immunological monitoring assays at present are the need for more consensual validations of the utility of these assays in different laboratories, more standardization and better controls of techniques, and improvement in the technology of the assays to permit rapid, reproducible, and accurate results with a lesser expenditure of laboratory time and money and greater economy in demands for recipient blood and donor tissue. Finally, immunological monitoring assays are notable for the great promise they offer in terms of immunobiological probes to dissect mechanisms of rejection, mechanisms of graft facilitation, mechanisms of action of immunosuppressive agents, and mechanisms by which empirical technology of recipient pre-treatment may condition the host to better acceptance of an incompatible graft.     

The role of the advanced practice nurse in the care of organ transplant recipients

The role of the advanced practice nurse (APN) in transplantation has evolved from the role of the clinical transplant coordinator. This report attempts to define the credentials, practice domains, barriers to practice, and reimbursement issues related to APN practice while contrasting the role with that of clinical transplant coordinator. The nephrology APN working in a collaborative transplant practice can be an integral part of a multidisciplinary health care team. The APN's education and credentials empower them to provide a wider scope of services than transplant coordinators who are "experts by experience." These services can include providing primary care and performing procedures such as percutaneous transplant biopsies, insertion of peripheral and central venous catheters, and wound debridement as well as management of patients along their continuum of transplant care. Patient education and advocacy also are key components of APN practice. In addition, the services the APN provides generally are reimbursable and therefore can provide revenue for the practice.