International Journal of Organ Transplantation Medicine
Volume:11 Issue: 3, Summer 2020

Patients with end-stage renal disease (ESRD) undergo a transition of care between their primary nephrologist and the transplant center during evaluation for kidney transplantation. Due to medical complexity, high hospitalization rate, and involvement of multiple medical stakeholders, transitions of medical care among patients with ESRD are likely to be associated with suboptimal care and medical errors. Provider-to-provider communication improves outcomes among ESRD patients transitioning between dialysis and transplant. There is little data analyzing proper transition of care between the nephrologist and the transplant center (TC).

Using survey methodology, we examined nephrologists’ current practice and experience regarding patient-related communication with the TC.

From among 822 nephrologists who were following at least 20 ESRD patients, we randomly selected 252 nephrologists to participate in the study. The survey consisted of 102 multiple choice and Likert-style items probing perceptions about various aspects of transplant, including communication between TC and nephrologist. Responses from 216 participants who submitted complete responses were included in the final analysis.

Depending on the phase of transplant, nephrologist-TC communication varied between 50%– 81% of nephrologists. Factors associated with higher likelihood of nephrologist-TC communication included attending transplant-related educational activity, practicing in a group with more than 5 nephrologists, and having more than 50 patients on dialysis. The majority of nephrologists indicated satisfaction with access to an attending physician in the TC, receiving timely and adequate information from the TC about their patients. Factors associated with higher likelihood of nephrologist satisfaction regarding communication with the TC included attending national nephrology meetings, medical directorship of a dialysis unit, fellowship training at an institution with an on-site transplant program, and availability of more than 2 transplant centers within 50 miles.

There is a lack of evidence-based guidelines for patient transfer of care between nephrologists and transplant centers during various phases of transplant referral, evaluation and post-transplant care. We found that the likelihood of the nephrologists’ communication with the transplant center and their satisfaction with the communication are related to their training, participation in continuing educational meetings, their practice location and size, and the overall composition of their patient population.

Chronic renal dysfunction (CRD), as predominantly related to calcineurin-inhibitor (CNI) nephrotoxicity, is associated with increased morbidity and mortality after lung transplantation (LTx). Basiliximab (BSX), a recombinant chimeric monoclonal antibody against CD25+ on activated T-lymphocytes, although often employed as an “induction immunosuppression” after solid organ transplantation, may further allow for reduction in CNI exposure with monthly administration and amelioration of CRD.

To determine the effect of monthly anti-CD25+ treatment with basiliximab on the progression of chronic renal dysfunction after lung transplantation.

Post-LTx recipients with stages IIIB-V CRD were treated with monthly intravenous infusion of BSX 20 mg. They were analyzed for creatinine clearance at 1, 3, 6, and 12 months; rate of the change in the clearance (the slope of the regression line) and FEV1 /month; de novo HLA class I or II DSA; and infectious events (IE). Tacrolimus (TAC) trough levels were concurrently targeted at 2–4 ng/mL during BSX therapy. The criteria for BSX discontinuation included acute lung allograft rejection, acute respiratory infection, and progression to end-stage renal disease (ESRD).

9 LTx recipients were treated with BSX for ≥6 months. The median time past after their LTx was 1853 (range: 75–7212) days; the mean±SD age was 64.3±11.3 years; the male:female ratio was 7:2. The baseline mean±SD creatinine clearance 1–3 months prior to BSX initiation was 22.8±5.14 mL/min/1.73 m2 (CI: 3.95) consistent with CRD stages—IIIB (2), IV (6), and V (1). Prior to BSX treatment, all 9 patients had established CLAD—obstructive-phenotype (BOS, n=4) and restrictive-phenotype (RAS, n=5). During the course of BSX treatment, the aggregate creatinine clearance mean slope increased by a mean±SD of 0.747±0.467 mL/min/1.72 m2 /month (CI: 0.359), consistent with “stabilization” of renal function in 7 patients; deterioration occurred in 2 with transition to chronic hemodialysis. Spirometric stability in lung allograft function was observed in 5 patients with a mean±SD aggregate FEV1 slope of -1.49±1.08 mL/month (CI: 2.50). 3 deaths occurred due to the following conditions during BSX treatment—HFpEF/ Sepsis + CLAD/Parainfluenza type 2 bronchiolitis + CLAD. 2 recipients developed “weak MFI” HLA class II DSA; no HLA class I DSA was detected during the treatment.

Renal sparing therapy with monthly BSX infusion with concurrent reduction in CNI exposure (TAC = 2–4 ng/mL) for stages IIIB-V CRD was associated with stability in creatinine clearance in 78% of patients over a treatment course of 6–12 months. Pre-existing CLAD afflicting all patients and inherent variability in progression of chronic rejection, limits our assessment of BSX efficacy in this context. We detected an infrequent de novo HLA class II DSA during BSX therapy

Persistent hypercalcemia and hyperparathyroidism after successful kidney transplantation can be detrimental in some recipients and should be ameliorated.

To point out the concerns regarding resistance to cinacalcet in kidney transplant recipients with persistent hypercalcemia.

14 renal transplant recipients who received cinacalcet treatment because of persistent hypercalcemia were included in the study. Serum creatinine, estimated glomerular filtration rate (eGFR), calcium, phosphorus, and intact parathyroid hormone (PTH) levels at the baseline and throughout the treatment, and ultrasonography and parathyroid scintigraphy findings were recorded.

Cinacalcet treatment was initiated after a mean±SD of 20.7±19.7 months of transplantation and maintained for 16.9±7.9 months. Serum calcium levels were significantly decreased with the cinacalcet treatment. There were no significant changes in serum creatinine, eGFR, phosphorus, and PTH levels. In all participants, serum calcium levels were increased from 9.8±0.6 to 11.1±0.6 mg/dL (p<0.001) within 1 month of cessation of cinacalcet. 7 recipients with adenoma-like hyperplastic glands underwent parathyroidectomy (PTx) due to failure with cinacalcet.

Cinacalcet may be an appropriate treatment for a group of recipients with hypercalcemia without adenoma-like hyperplastic glands or who had a contraindication for surgery. Recipients with enlarged parathyroid gland may resist to cinacalcet-induced decrease in serum PTH, although the concomitant hypercalcemia may be corrected.

Patients with chronic liver failure (CLF) faced serious medical conditions including the oral cavity.

To investigate the prevalence of oral mucosal lesions, saliva flow rate, and dental complications in candidates of liver transplant surgery.

In this cross-sectional study, oral and dental health of 77 patients with CLF and 77 healthy individuals were assessed for oral mucosal lesions, salivation rate, DMFT (decayed, missing, filled teeth) index, and bone level. To carefully determine the indices and examine the patients thoroughly, a panoramic radiography was also taken from each participant.

The frequency of oral mucosal lesions in patients was significantly (p<0.001) higher than the comparison group. The most frequent lesion identified was angular cheilitis followed by candidiasis. The mean saliva flow rate in the patients (0.85 g/min) was also significantly (p<0.001) lesser than that in healthy individuals (1.58 g/min). The DMFT index and bone level were not significantly different between the two groups. Nor was a correlation between the MELD score and each of DMFT index, bone loss, or oral mucosal lesions.

Mucosal lesions, especially fungal-related lesions, are more prevalent in the oral cavity of patients with CLF. The saliva production rate is reduced due to various medications used in this group. Patients with CLF are prone to oral infections and a thorough oro-dental examination is crucial in this group of patients. Vigorous oral hygiene instructions should be offered to liver cirrhosis individuals.

Early oral feeding, as one of the most important components of multimodal strategies referred to as Enhanced Recovery After Surgery (ERAS), is now widely adopted for optimization of postoperative recovery of surgical patients.

To assess ERAS outcome in patients who underwent liver transplantation in our center.

In a prospective study, patients who underwent liver transplantation from April 2015 to June 2018 at Imam Khomeini Hospital Complex, affiliated to Tehran University of Medical Sciences, Tehran, Iran, were enrolled in this study. Serum albumin, total iron-binding capacity (TIBC), and course of hospital stay were assessed.

39 (23 male) patients who underwent choledochojejunostomy with Roux-en-Y anastomosis for liver transplantation were enrolled. The mean±SD pre-operative serum albumin and TIBC levels of patients were 3.0±0.6 (range: 1.9–4.1) g/dL and 304±75 (range: 154.0–437.0) µg/dL, respectively. The mean±SD time between the end of operation and starting oral feeding was 11.6±1.8 (range: 9.0–15.0) hours. All patients tolerated early oral feeding with liquids followed by solid foods; no vomiting reported in patients. Overall, patient survival rates at one month and three months were 89.7% and 89.7%, respectively. In our study, no leak of anastomosis was reported.

There was no major harm for ERAS after liver transplantation and it might be even helpful as in colorectal surgeries. As seen in our study, oral feeding was started as soon as possible after the end of operation in almost all patients and all of them tolerated early oral feeding. No one had vomiting or nausea.

In care of brain-dead patients, nurses face several challenges. It is important to determine
the context behind these challenges since they affect the performance of nurses and the organ donation
process.

To identify factors affecting the emergence of challenges related to the management of braindead patients by nurses in the donation process.

In this qualitative conventional content analysis, data were collected by performing 28 semistructured and in-depth interviews with nurses working in the ICUs. Purposive sampling started from
March 2014 until saturation, which was reached in June 2016. Data analysis occurred simultaneously
with data collection.

Qualitative analysis of contents provided from interviews led to the extraction of themes that
showed the experience of nurses about the challenges of caring for brain-dead patients in the donation
process. These themes included “doubt and conflict in accepting the situation” and “defects in an effective and targeted care system.” In the end, the main theme of “inconsistency and incompatibility of care
management” was abstracted.

According to the results of the study, factors involved in the emergence of challenges for nurses in care management included defects in education or managerial problems, which increased tension
for nurses.