Acute suicidal intoxication with tacrolimus in a kidney transplant patient

A case of a 23-year-old female, after renal transplant, who had tried to commit suicide with 100 mg of Prograf was described. In the presented case despite the relatively high tacrolimus blood concentration level (>30 microg/l) only severe 5-hour lasting headache and short-term mild hyperglycaemia (7.22 mmol/l), hyperkalemia (5.4 mmol/l) and considerable leukocytosis (19.52 x 10(3)) were observed. In this case there was mild clinical course of intoxication despite tacrolimus high blood concentration. It could not be excluded that early administration of gastric lavage and activated carbon was partly responsible for mild course of poisoning.

Comparative psychosocial analysis of patients on maintenance hemodialysis and transplanted patients

OBJECTIVE

Many previous studies have shown that renal transplantation is associated with superior psychosocial rehabilitation than patients on dialysis. Our objective was to test if the same findings apply in Saudi patients.

PATIENTS AND METHODS

Questionnaires probing demographic data, income, mental status, literacy and unemployment rates, family support, home ownership, satisfaction with previous transplantation and views and preferences about different types of transplantation were distributed to transplanted patients (n= 150) and patients on maintenance hemodialysis (HD) (n=210) at the Jeddah Kidney Center, King Fahd Hospital, Jeddah, Saudi Arabia. Illiterate patients were helped in completing the questionnaires by the social worker.

RESULTS

We found that the male to female ratio in the transplanted group was 1.7:1 whereas it was 1:1 in the HD group. It was also found that more people in the transplant group owned houses than in the HD group (52% vs. 36.7%). Twice as many transplanted patients earned more than 7000 Saudi Riyals monthly. The unemployment rates were equal in the two groups (25-26%). Interestingly, the rate of illiteracy in the transplant group was almost half the rate in the HD group. More transplanted patients were assessed as being mentally balanced and, rational (92%) as compared to 66.2% in the HD group. Gratifyingly, however, both groups reported solid family support in the majority of patients (>80%). Of particular interest was the finding that well over one third (37%) of the patients on dialysis preferred to have live-unrelated transplants. This is far higher than those wishing for live-related (16.7%) or cadaveric (17.1%).

CONCLUSION

Many of our findings coincide with what has been reported earlier. More patients with higher income were transplanted and there was no detected improvement in the employment rate associated with transplantation. Moreover, the vast majority of patients (92.7%) had no objection to receiving a living unrelated kidney and, in fact, as many as 37.6% actually felt preference for a living unrelated kidney over other types of transplantations.

Assessment of the willingness of potential live related kidney donors

Even in the case of live related kidney donation, coercion within families is applied on the most vulnerable amongst them. This vulnerability could be financial, social or psychological In this paper we discuss how to assess the willingness or unwillingness of a kidney donor and discover if any coercion has been applied on him/her be it direct or indirect.

The Annelies factor--on human bonding in transplantation

A third-party observer's view on the work of a clinical psychologist among kidney transplant donors and recipients prior to first-ever organ transplant in Yemen is presented. Universal, cross-cultural aspects of this emotionally difficult situation are underlined on the background of this unique experience in organ transplantation.

Barriers to employment following renal transplantation: implications for the social work professional

The biopsychosocial model was used to analyze data from an open-ended item in a survey of individuals following kidney transplantation. After sending surveys to kidney transplant recipients at a large, Midwestern teaching hospital, this work analyzed the themes that emerged from an inquiry into factors that affected their ability to return to work or switch jobs. The results revealed that concerns reflecting biological/ psychological factors were most frequently indicated followed by social concerns. That is, the majority of the responses were related to a physical disorder or condition (biological) that appeared to have been directly related to a psychological response to it. This was followed by social concerns primarily related to health insurance. Thus, the researchers involved in this study conclude that social workers in health care must: (1) consistently embrace the assumptions of the biopsychosocial model so that the most inclusive assessments and interventions can be rendered, while (2) remaining knowledgeable regarding legislative changes that impact health insurance coverage for this specific population.

Asclepiad's cock: a patient-physician association is a useful tool for educational programs in nephrology, dialysis, and transplantation

BACKGROUND

The negative impact of the mass media, the lack of information, and the request for in-depth knowledge are the basis for the present need for educational programs on transplantation, brain death, and chronic kidney diseases end-stage renal disease; (ESRD). The aim of the present article was to critically review the activities performed by Il Gallo di Esculapio, a nonprofit association, in the education on the different phases of ESRD. The associates are physicians and patients, and the activities are integrated institutionally.

METHODS

This report is a narrative review of the material produced and performed by Il Gallo di Esculapio ONLUS in 1996-2004.

RESULTS

The two main activities developed were book writing and an educational program. Eight books for patient education were written on different aspects of dialysis, transplantation, and ESRD. Most were designed as theses of the Medical School. Cooperation with patients was important in all cases and fundamental for the collection of interviews.

EDUCATION

A 4-hour educational program on transplantation started in 2000-2001 (1 high school was involved). The checklist originally included only transplantation and organ donation, but progressively gave space also to dialysis, ESRD, and social health care problems. In 2003-2004 the program involved 67 high schools. The association coordinated progressive patient involvement.

CONCLUSION

Small, nonprofit patient-physician associations linked with the University allow enrolling resources for educational activities to often-neglected parts of the medical profession.

Assessing associations between medication adherence and potentially modifiable psychosocial variables in pediatric kidney transplant recipients and their families

Post-transplant immunosuppressant (IS) medication adherence is essential for long-term graft survival and relatively little is known about psychosocial barriers that interfere with optimum medication adherence in pediatric kidney transplant patients. The objective of this prospective observational cohort study was to assess the impact of modifiable psychosocial variables on medication adherence. Our hypothesis was that parental stress, dysfunctional parent-child interactions and child behavior problems would be associated with poorer medication adherence. Thirteen pediatric kidney transplant patients and their caregivers were enrolled. Transplant recipients who were able to read and caregivers of all the transplant recipients completed behavioral and attitudinal surveys. A subgroup of seven families dispensed their primary IS medication from an electronic monitoring vial (MEMS Smart Cap). For these patients, medication adherence was calculated by computing a ratio of the medication taken divided by the prescribed dose. In addition, for the entire group, serial IS levels were reviewed by two board certified pediatric nephrologists who categorized all 13 transplant recipient families as either 'probably adherent (PA)' or 'possibly non-adherent (PNA)'. Pearson correlation coefficients and independent samples Student t-tests were used to assess the association between medication adherence and psychosocial variables measured by standardized questionnaires. In this study, elevated parental stress, dysfunctional parent-child interactions, and child behavior problems were associated with poorer medication adherence. In addition, we found evidence to support the relationship between subjective dissatisfaction with appearance and poorer medication adherence. These findings suggest that pre-transplant recipient evaluations of risk factors for poor adherence are warranted.

Psychological effects of living related kidney transplantation - risks and chances

BACKGROUND

Recipients of living donor kidney transplantation hope for an improved physical well-being after transplant. Furthermore the patients and their relatives frequently expect an improvement in their psychological findings in consequence of the living related transplantation. The present study examines the psychosocial effects of living donor kidney transplantation for donors and recipients under successful as well as complicated circumstances.

MATERIAL AND METHODS

Based on 31 catamnestic interviews of recipient-donor couples and a content analysis of these interviews, hypotheses regarding the psychological requirements for a successful progression of a living kidney donation are deduced and put forward.

RESULTS

The aspiration for an improvement of psychological problems, particularly anxiety and depression, as an effect of transplantation can on the basis of the present results not be supported. Living donor kidney transplantation between close recipient and donors must not be regarded as a means to solve psychological problems and familial conflicts. An attitude characterized by realistic and modest expectations as well as relationships, which have been cleared of extreme conflicts prior to the transplantation could facilitate a favourable psychological progression.

Medication compliance among renal transplant patients: a Hospital Kuala Lumpur experience

This survey aims to identify prevalence, reasons and predictors of noncompliance among renal transplant patients followed up in Hospital Kuala Lumpur (HKL). All adult renal transplant patients who were at least 6 months post transplant were recruited from 10/2001 till 5/2002. Patients who consented were interviewed by a medical doctor or research assistant based on questionnaire. Noncompliers were defined as those who missed or self adjusted any dose of immunosuppressant within the preceding 4 weeks. Inter-rater agreement was assessed prior by Kappa (K) scores and they were acceptable. Out of 304 patients, 246 patients volunteered; of whom 144 (58.5%) were males. Twenty-one (9.3%) were noncompliers. Reasons for noncompliance included forgetfulness (n=8), financial constraints (n=1), fear of rejection (n=1), side effects (n=9), decision not to take (n=6), difficulty in breaking medication into correct dosages (n=1). Significant predictors of noncompliance were longer duration of transplant noncompliance to other drugs, regular use of nonprescription drugs; the lack of symptoms of fat facial cheeks and infection. Surveillance for noncompliance should not be relaxed as its predictors are diverse and persistent, especially in those who are at high risks.

A Numerical Scale Comparison of Renal Transplant Recipient Experience with and Opinions about Calcineurin Inhibitors

BACKGROUND

Many studies compare the relative benefits of cyclosporine and tacrolimus with respect to graft and patient outcomes, but comparative renal transplant recipient opinion on calcineurin inhibitor (CI) use has not been directly sought.

METHODS

We administered a confidential clinic-distributed written questionnaire to adult single-organ recipients pertaining to CI use and related physical side effects experienced. Sixteen common immunosuppressive therapy-related side effects were rated on a 1-10 Likert numerical scale, with 1 meaning complete disagreement and 10 complete agreement with their own CI experience. Comparisons were made among recipients on cyclosporine, tacrolimus, and those with a dual drug experience.

RESULTS

The questionnaire was filled by 316 patients. The efficacy of cyclosporine and tacrolimus was considered equivalent (p = 0.99), while the overall side effect profile reported was greater for cyclosporine (p = 0.001). The side effect profile for cyclosporine was greater in the dual group than the cyclosporine-only group (p = 0.01). Cyclosporine was perceived as more difficult to swallow (p = 0.001), nephrotoxic (p = 0.005), and to cause more hypertension (p = 0.04) and hyperlipidemia (p = 0.001), while tacrolimus was perceived to be more neurotoxic (p < 0.0001), but not causing more diabetes (p = 0.64).

CONCLUSIONS

Renal transplant recipients experience fewer and less severe side effects with tacrolimus. Further contemporaneous study of CI preferences in this population is warranted. Transplant centers should consider patient opinion in tailoring their own immunosuppressive strategies and regimens.

Donor-recipient interaction: the Heidelberg model of evaluation and consultation

BACKGROUND

In order to avoid psychological complications in living-donor transplantation, careful evaluation and consultation of the donor-recipient system is necessary. This article describes the Heidelberg consultation procedure before and after transplantation. This approach emphasizes close collaboration between physician and psychologist in joint interviews.

METHODS

Consultations focus on family genogram, the history of the donation idea; stability and balance of relationship; expectations; hesitations and doubts; discussion of complications; previous hospital experiences; the offer to provide crisis intervention when needed.

RESULTS

In 20% of all cases, unresolved problems appear. These include: unilaterally dependent relationships; unrealistic hopes for change; anxious avoidance to reflect complications; lack of medical information; risky health behaviour; negative experiences with hospitals. When properly consulted, half of these couples resign from transplantation.

CONCLUSIONS

Close physician-psychologist collaboration adds significant value to a 'psychologist-only' consultation. Discussing hesitations and concerns strengthens confidence in the professional transplantation system. Access to post-transplant consultation needs further improvement.

Role of patient-support groups in the Thailand transplant program

Thailand started kidney transplantation in 1972 when vascular and nonvascular transplant programs were first established. Presently, we have 27 kidney, 6 liver, and 6 intrathoracic private or governmental transplantation centers, all approved and members of the Organ Donation Centres Thai Red Cross Society (ODC). They also provide organ procurement teams to the ODC. The Thai Medical Council has issued and supervised the criterion of brain death and ethical rules of transplantation to all practicing physicians since 1989. All recipients must register at these selected transplantation centers and at the ODC. When the potential donor arrives from any hospital in Thailand, the donor hospital notifies the ODC and organ procurement teams are sent out to harvest organs and transfer them to the recipient transplantation centers. The ODC computerizes and shares organs according to ABO, HLA typing, and crossmatching results. After transplantation all patients register with the Thai Transplantation Society (TTS) and the ODC. The TTS, the Thai Transplant Coordinator Society, and the ODC are responsible for the education of surgeons, physicians, nurses, patients, the public, and mass media to improve our transplant program. Bone marrow transplantation has separate regulations. Pooled, nonrelated bone marrow donors are registered at the blood-bank of the Thai Red Cross Society to provide donors for bone marrow transplantation. Financially, government support recipients only if they are state enterprise workers or civil servants. Public fund support through the ODC for organ procurement and the Kidney Foundation of Thailand is available for kidney transplantation. The ODC and the transplantation centers are the main patient-support groups for transplant programs in Thailand.

Attitudes of black South Africans to living related kidney transplantation

Between September 1992 and April 2003, 96 patients in chronic renal failure had 134 potential related living donors. The aim of this study was to determine the factors that influence living related kidney transplantation among black South Africans.

METHODS

Potential recipients and donors were screened for suitability to donate or receive kidneys. The relationship of the donor to the recipient was documented.

RESULTS

Ninety-six potential recipients of median age 32 years (range, 7 to 53) and a female to male ratio of 1:1.6 had potential related donation from 47 sisters, 33 brothers, 27 mothers, 8 fathers, and 11 children. Eight potential donors were from cousins, spouses, stepbrothers, and friends. One, two, or three potential donors per recipient were counted among 54, 19, and 10 recipients, respectively. Contraindications to transplantation in 45 potential donors were ABO incompatibility (n = 19); hypertension (n = 11); HIV positivity (n = 10); and one each for nephrotic syndrome, gastric cancer, Hepatitis B, withdrawal, and a single functioning kidney. Thirty-five patients were transplanted from relatives. Although HLA-A, B, and DR antigens were studied in transplanted patients using both serologic and polymerase chain reaction-sequence-specific oligonucleotide methods, HLA matching was not used for donor selection. Only two living related pairs were HLA identical. Actual 1-year graft survival after transplantation was 95%. In conclusion, the concept of related living donation is acceptable among black South Africans and the number of donors per recipient suggests that HLA matching can be improved.

Modifiable risk factors for non-adherence to immunosuppressants in renal transplant recipients: a cross-sectional study

BACKGROUND

Non-adherence to immunosuppressants is a major cause of renal transplant failure. Interventions to improve adherence need to target modifiable risk factors.

METHODS

Adherence was measured using the 'gold standard' measure of electronic monitoring in 58 adult renal transplant recipients from a UK transplant unit. Subjects were identified from a stratified random sample of 153 recipients recruited to a larger cross-sectional study comparing different measures of adherence. Inclusion criteria included age over 18 years and a functioning renal transplant, transplanted 6-63 months previously. Exclusion criteria included residence outside the region served by the unit and inability to give informed consent. Health beliefs, depression and functional status were measured using standardized questionnaires (Beliefs about Medicines Questionnaire, Illness Perception Questionnaire, Revised Clinical Interview Schedule and SF-36) and semi-structured interview. Transplant and demographic details were collected from the notes.

RESULTS

Seven [12%, 95% confidence interval (CI) 4-20%] subjects missed at least 20% of days medication and 15 (26%, 15-37%) missed at least 10% of days. Lower belief in the need for medication and having a transplant from a live donor were the major factors associated with non-adherence. Depression was common, although not strongly associated with non-adherence.

CONCLUSIONS

Beliefs about medication are a promising target for interventions designed to improve adherence. The lower adherence in recipients of transplants from live donors needs confirming but may be clinically important in light of the drive to increase live donation.

Quality of life and mood in renal transplantation recipients, donors, and controls: preliminary report

Currently, living related donors are involved in approximately 85% of all kidney transplantations performed at our institution. Health-related quality of life (HRQL) is an important outcome factor in chronic disease. Quality of life may be diminished by prolonged illness or certain treatment modalities and by negative, disabling effects on mood. We investigated HRQL and mood in renal transplant recipients, donors, and controls using the Beck Depression Inventory, Beck Anxiety Inventory, and 36-item Short Form Health Survey. Recipient depression scores were significantly higher (indicating more serious depression) than those of donors (P <.05), but similar to those of the controls. There was no significant difference between the donor and the control subjects' depression scores. The anxiety scores of the recipients and donors were similar; and recipient anxiety scores were significantly higher than those of the control subjects (P <.05). The recipient scores indicated significantly poorer physical functioning (P <.001), significantly greater physical limitation on roles (P <.01), and lower levels of general health (P <.01) compared to controls. The recipient scores for vitality, pain, social functioning, and emotional limitations on roles were similar to those of the controls. Our results indicate that most recipients and donors experience anxiety after renal transplantation. This study confirms that recipients have favorable outcomes with respect to social functioning and emotional well-being. Overall, the results of this preliminary study are positive, encouraging us to continue to perform living donor kidney transplantation.

Quality of life in cadaver and living-related renal transplant recipients in Kuala Lumpur hospital

OBJECTIVE

To examine the quality of life in cadaver (CAD) and living-related (LRRT) renal transplant recipients.

METHODS

A cross-sectional study was done on patients followed in renal transplant clinic from 1/4/03 to 1/7/03 using the SF-36 questionnaire. Inclusion criteria were age >16 years,minimum of 3 months' posttransplant, and informed consent. Exclusion criteria were current treatment for rejection or infection or any life-threatening conditions. Information on duration of transplant, duration of dialysis prior to transplant, number of co-morbidities, and sociodemodraphic data were collected.

RESULTS

Sixty-four among 110 patients (58.1%) completed the SF36 questionnaire. The LRRT recipients were younger, had a longer duration of transplant, and had spent significantly less time on dialysis prior to transplant compared to CAD transplant patients. Overall, the physical composite and the mental composite scores were not significantly different between the two transplant groups. Age was negatively associated with the physical composite score (Spearman's rho -0.251, P < .05) and bodily pain (Spearman's rho -0.266, P < .05). Duration of dialysis prior to transplant was negatively correlated with social functioning (Spearman's rho -0.28, P < .05) and mental health (Spearman's rho -0.39, P < .005). In multiple regression analysis, age was a significant predictor of the SF36 physical composite score (P < .05).

CONCLUSION

This study shows that the quality of life between LRRT and CAD recipients was not significantly different. Increased age was associated with poorer physical capacity.

Prospective study on late consequences of subclinical non-compliance with immunosuppressive therapy in renal transplant patients

In this prospective study we compared the incidence of late acute rejections (LAR) and changes in serum-creatinine over time between compliers and noncompliers with immunosuppressive therapy more than 1 year post transplantation and explored the relative contribution of non-compliance and other risk factors in the occurrence of LAR. One hundred and forty-six adult renal transplant recipients were followed during a 5-year period. Patients were interviewed at the beginning of the study and categorized as non-compliers if they admitted to have skipped immunosuppressive medication on a regular basis during the previous 12 months. The occurrence of LAR during the follow-up period was recorded. We identified 22.6% non-compliers of which 21.2% experienced a late acute rejection compared with 8% in the group of compliers at 5 years postinclusion (p < 0.05). Kaplan-Meier survival analysis showed a decreased rejection free time in non-compliers compared with compliers (p = 0.03). Non-compliant patients had a 3.2 higher risk of LAR (Cox regression analysis, p = 0.005). Non-compliers experienced a higher increase in serum-creatinine over time (Linear Mixed Models, p < 0.001). Non-compliance in renal transplant patients more than 1-year post transplantation is associated with an increased risk for LAR and a higher increase in serum-creatinine during the following 5 years.

Living kidney donors' long-term psychological status and health behavior after nephrectomy - a retrospective study

BACKGROUND

The aim of the study was a comprehensive psychological evaluation of living kidney donors. Existing studies indicate a high donor satisfaction with the decision to donate and good donor quality of life in short-term, as well as in long-term follow-up periods. In many studies, questionnaires with only a few items have been used to assess psychological health or well-being; however, most studies exclusively measured quality of life. Therefore, our retrospective single center study applied a broad assessment of psychological variables. We evaluated whether standardized, differentiated and specific psychological research instruments confirmed the positive, long-term condition of kidney donors as reported in the scientific literature, albeit based on a limited set of variables.

METHODS

From 1973 to 2001, 152 nephrectomies were performed in Frankfurt. In the context of a detailed medical follow-up examination, a psychological study was implemented using a semi-structured interview and a set of four standardized, well-established questionnaires. Overall, data from 145 donors was included in the medical follow-up and 112 donors participated in the psychological investigation.

RESULTS

The mean age of donors was 55.9 (+/- 10.7) yrs at follow-up, and the time-since-donation was 11.2 (+/- 7.5) yrs. Donors scored better on a wide range of the psychological scales such as psychological symptoms, health behavior and health consciousness that was to be expected in comparison with data from representative German population samples. Nearly all donors (97%) would choose to donate again, and 91% remain entirely satisfied with their decision.

CONCLUSION

The study demonstrates that existing results, reporting positive long-term psychological donor well-being, could be confirmed by a set of comprehensive, standardized and multi-methodological psychological instruments.

Noncompliance after kidney transplantation: a systematic review

We performed a systematic review of the literature on medical noncompliance after kidney transplantation in the cyclosporine era. We wished to define commonalities that may help the clinician identify patients for early intervention. We found that patients who were at a higher risk of noncompliance after kidney transplants were younger, female, unmarried, and non-Caucasians. Patients who were recipients of living donor transplants and had been transplanted for a longer time with a history of a previous transplant were also at risk of noncompliance. We also found that patients displaying emotional problems, such as anxiety, hostility, depression, distress, lack of coping, and avoidant behaviors, were also at risk for noncompliance after kidney transplantation.