Telemedicine for Outpatient Care of Kidney Transplant and CKD Patients

The SElf-Care After REnal Transplantation Study: A Retrospective Evaluation of a Home-Monitoring Program Implemented as Standard Care

After transplantation self-management is essential for graft survival and optimal quality of life. To address the need for home-based support in self-management, we implemented the "SelfCare after Renal Transplantation" (SeCReT) box, containing home-monitoring equipment combined with a smartphone application that was linked to the electronic patient records. This study investigated the uptake and continuation, protocol adherence, and subjective evaluation of this home-monitoring program. All "de novo" kidney recipients who received the SeCReT-box in the study period (Aug 2021-Dec 2022) were eligible for inclusion. Protocol adherence was defined as ≥75%. Subjective evaluation was assessed with a 5-item questionnaire. Of the 297 recipients transplanted, 178 participants (60%) were included in the analysis. Protocol adherence was 83%, 73%, 66%, and 57% respectively at 5, 10, 20, and 40 weeks of the protocol. With regard to continuation, 135 participants were still in the program at the end of the study period (75% retention rate). Regarding subjective evaluations, 82% evaluated the program positively, and 52% reported lower care needs due to home-monitoring. Results are positive among those who entered and continued the program. Qualitative research is needed on barriers to entering the program and facilitators of use in order to promote optimal implementation.

Evaluation of Telemedicine Consultations Using Health Outcomes and User Attitudes and Experiences: Scoping Review

BACKGROUND

Despite a recent rise in adoption, telemedicine consultations retention remains challenging, and aspects around the associated experiences and outcomes remain unclear. The need to further investigate these aspects was a motivating factor for conducting this scoping review.

OBJECTIVE

With a focus on synchronous telemedicine consultations between patients with nonmalignant chronic illnesses and health care professionals (HCPs), this scoping review aimed to gain insights into (1) the available evidence on telemedicine consultations to improve health outcomes for patients, (2) the associated behaviors and attitudes of patients and HCPs, and (3) how supplemental technology can assist in remote consultations.

METHODS

PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guided the scoping review process. Inclusion criteria were (1) involving adults with nonmalignant, noncommunicable chronic conditions as the study population; (2) focusing on health outcomes and experiences of and attitudes toward synchronous telemedicine consultations between patients and HCPs; and (3) conducting empirical research. A search strategy was applied to PubMed (including MEDLINE), CINAHL Complete, APA PsycNet, Web of Science, IEEE, and ACM Digital. Screening of articles and data extraction from included articles were performed in parallel and independently by 2 researchers, who corroborated their findings and resolved any conflicts.

RESULTS

Overall, 4167 unique articles were identified from the databases searched. Following multilayer filtration, 19 (0.46%) studies fulfilled the inclusion criteria for data extraction. They investigated 6 nonmalignant chronic conditions, namely chronic obstructive pulmonary disease, diabetes, chronic kidney disease, ulcerative colitis, hypertension, and congestive heart failure, and the telemedicine consultation modality varied in each case. Most observed positive health outcomes for patients with chronic conditions using telemedicine consultations. Patients generally favored the modality's convenience, but concerns were highlighted around cost, practical logistics, and thoroughness of clinical examinations. The majority of HCPs were also in favor of the technology, but a minority experienced reduced job satisfaction. Supplemental technological assistance was identified in relation to technical considerations, improved remote workflow, and training in remote care use.

CONCLUSIONS

For patients with noncommunicable chronic conditions, telemedicine consultations are generally associated with positive health outcomes that are either directly or indirectly related to their ailment, but sustained improvements remain unclear. These modalities also indicate the potential to empower such patients to better manage their condition. HCPs and patients tend to be satisfied with remote care experience, and most are receptive to the modality as an option. Assistance from supplemental technologies mostly resides in addressing technical issues, and additional modules could be integrated to address challenges relevant to patients and HCPs. However, positive outcomes and attitudes toward the modality might not apply to all cases, indicating that telemedicine consultations are more appropriate as options rather than replacements of in-person visits.

Removing the physician from the equation: Patient-controlled, home-based therapeutic drug self-monitoring of tacrolimus

The dosing of tacrolimus, which forms the backbone of immunosuppressive therapy after kidney transplantation, is complex. This is due to its variable pharmacokinetics (both between and within individual patients), narrow therapeutic index, and the severe consequences of over- and underexposure, which may cause toxicity and rejection, respectively. Tacrolimus is, therefore, routinely dosed by means of therapeutic drug monitoring (TDM). TDM is performed for as long as the transplant functions and frequent and often lifelong sampling is therefore the rule. This puts a significant burden on patients and transplant professionals and is associated with high healthcare-associated costs. Furthermore, by its very nature, TDM is reactive and has no predictive power. Finally, the current practice of TDM does not foresee in an active role for patients themselves. Rather, the physician or pharmacist prescribes the next tacrolimus dose after obtaining the concentration measurement test results. In this article, we propose a strategy of patient-controlled, home-based, self-TDM of the immunosuppressant tacrolimus after transplantation. We argue that with the combined use of population tacrolimus pharmacokinetic models, home-based sampling by means of dried blood spotting and implementation of telemedicine, this may become a feasible approach in the near future.

The feasibility of integrating a home telehealth model for older persons living with hemodialysis

BACKGROUND

In Thailand, there is a rapidly increasing population of older persons living with hemodialysis (OPLWH) for whom quality of life and clinical outcomes are their main focus. This study aims to assess the feasibility of an integrated home telehealth model on quality of life and laboratory parameters of OPLWH.

METHODS

In this study, the second phase of a mixed methods exploratory sequential design was conducted using a repeated measures experimental design. Participants met the inclusion criteria, which included being an OPLWH at a single hemodialysis center of one hospital in Chiang Mai province, Thailand, during the experimental period between 1 April and 30 September 2018, and willing to participate in the study. The 54 participants were purposively selected and randomly assigned to receive either an intervention (n = 24) consisting of health education and health monitoring using a telehealth device (an iPad) and a web application, or usual care (n = 30). The instruments included a demographic data form, which was analyzed using the chi-square test. The health-related quality of life questionnaire (the 9-item Thai Health Status Assessment questionnaire) and blood chemistry (BUN, Cr, Hb, Hct, Alb, K, Kt/V, and nPCR) were compared and measured at baseline, and at 3 and 6 months after enrolment using independent t-test and one-way repeated measures ANOVA.

RESULTS

The comparison of quality of life between the two groups at the two points of repeated measurement (after 3 months) showed a statistically significant difference in mental health scores at P < 0.05. Six months after the intervention, mean scores for health outcomes and patients' quality of life improved; however, this change did not reach statistical significance.

CONCLUSIONS

An integrated home telehealth model implemented by a hemodialysis nurse is a feasible holistic care approach for OPLWH. However, the absence of statistical significance may partly be associated with the clinical characteristics of frailty and risk factors such as increased age, hypertension, diabetes, heart disease, longer dialysis time, and inadequacy of Kt/V. Large-scale multi-centre trials are warranted to fully examine the acceptability of the model. The duration and long-term effects of the telehealth model are also recommended for further investigation.

PATIENT OR PUBLIC CONTRIBUTION

The development of a home telehealth model was a collaborative process between patients, caregivers, healthcare professionals from the hemodialysis unit, and the research team.

Telemedicine for Kidney Transplant Recipients: Current State, Advantages, and Barriers

Telemedicine is defined as the use of electronic information and communication technologies to provide and support healthcare at a distance. In kidney transplantation, telemedicine is limited but is expected to grow markedly in the coming y. Current experience shows that it is possible to provide transplant care at a distance, with benefits for patients like reduced travel time and costs, better adherence to medication and appointment visits, more self-sufficiency, and more reliable blood pressure values. However, multiple barriers in different areas need to be overcome for successful implementation, such as recipients' preferences, willingness, skills, and digital literacy. Moreover, in many countries, limited digital infrastructure, legislation, local policy, costs, and reimbursement issues could be barriers to the implementation of telemedicine. Finally, telemedicine changes the way transplant professionals provide care, and this transition needs time, training, willingness, and acceptance. This review discusses the current state and benefits of telemedicine in kidney transplantation, with the aforementioned barriers, and provides an overview of future directions on telemedicine in kidney transplantation.

Patient and Clinician Experiences With the Combination of Virtual and In-Person Chronic Kidney Disease Care Since the COVID-19 Pandemic

Background

Following onset of the COVID-19 pandemic, chronic kidney disease (CKD) clinics in BC shifted from established methods of mostly in-person care delivery to virtual care (VC) and thereafter a hybrid of the two.

Objectives

To determine strengths, weaknesses, quality-of-care delivery, and key considerations associated with VC usage to inform optimal way(s) of integrating virtual and traditional methods of care delivery in multidisciplinary kidney clinics.

Design

Qualitative evaluation.

Setting

British Columbia, Canada.

Participants

Patients and health care providers associated with multidisciplinary kidney care clinics.

Methods

Development and delivery of semi-structured interviews of patients and health care providers.

Results

11 patients and/or caregivers and 12 health care providers participated in the interviews. Participants reported mixed experiences with VC usage. All participants foresaw a future where both VC and in-person care was offered. A reported benefit of VC was convenience for patients. Challenges identified with VC included difficulty establishing new therapeutic relationships, and variable of abilities of both patients and health care providers to engage and communicate in a virtual format. Participants noted a preference for in-person care for more complex situations. Four themes were identified as considerations when selecting between in-person and VC: person's nonmedical context, support available, clinical parameters and tasks to be completed, and clinic operations. Participants indicated that visit modality selection is an individualized and ongoing process involving the patient and their preferences which may change over time. Health care provider participants noted that new workflow challenges were created when using both VC and in-person care in the same clinic session.

Limitations

Limited sample size in the setting of one-on-one interviews and use of convenience sampling which may result in missing perspectives, including those already facing challenges accessing care who could potentially be most disadvantaged by implementation of VC.

Conclusions

A list of key considerations, aligned with quality care delivery was identified for health care providers and programs to consider as they continue to utilize VC and refine how best to use different visit modalities in different patient and clinical situations. Further work will be needed to validate these findings and evaluate clinical outcomes with the combination of virtual and traditional modes of care delivery.

Trial registration

Not registered.

Challenges in the management of the kidney allograft: from decline to failure: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference

In March 2022, Kidney Disease: Improving Global Outcomes (KDIGO) held a virtual Controversies Conference to address the important but rarely examined phase during which the kidney transplant is failing or has failed. In addition to discussing the definition of a failing allograft, 4 broad areas were considered in the context of a declining functioning graft: prognosis and kidney failure trajectory; immunosuppression strategies; management of medical and psychological complications, and patient factors; and choice of kidney replacement therapy or supportive care following graft loss. Identifying and paying special attention to individuals with failing allografts was felt to be important in order to prepare patients psychologically, manage immunosuppression, address complications, prepare for dialysis and/or retransplantation, and transition to supportive care. Accurate prognostication tools, although not yet widely available, were embraced as necessary to define allograft survival trajectories and the likelihood of allograft failure. The decision of whether to withdraw or continue immunosuppression after allograft failure was deemed to be based most appropriately on risk-benefit analysis and likelihood of retransplantation within a few months. Psychological preparation and support was identified as a critical factor in patient adjustment to graft failure, as was early communication. Several models of care were noted that enabled a medically supportive transition back to dialysis or retransplantation. Emphasis was placed on the importance of dialysis-access readiness before initiation of dialysis, in order to avoid use of central venous catheters. The centrality of the patient to all management decisions and discussions was deemed to be paramount. Patient "activation," which can be defined as engaged agency, was seen as the most effective way to achieve success. Unresolved controversies, gaps in knowledge, and areas for research were also stressed in the conference deliberations.

Assessments of and Attitudes towards Specialist Teleconsultations among Nephrology and Posttransplant Outpatients during the COVID-19 Pandemic

In Poland, teleconsultations (TCs) were not legally regulated or even conducted until the COVID-19 pandemic, which necessitated their abrupt implementation and posed a challenge to patients and doctors. The aim of this study was to assess the quality of TCs and the satisfaction with this mode of consultation among nephrology and kidney transplant outpatients with a high risk of severe courses of SARS-CoV-2 infection. A self-designed questionnaire regarding patients' demographics; digital fluency; and participation in, satisfaction with, and attitude towards TCs was distributed among patients in the nephrology and posttransplant outpatient clinics at two hospitals in central Poland. The questionnaires were completed by 294 adult patients, of whom 72.1% (n = 212) had participated in TCs at one of the abovementioned clinics. Almost all (96.7%) of the TCs were conducted via phone, and in 94.8% of cases, they fulfilled the purpose of the consultation. The most commonly reported advantages were not having to leave home and the reduced risk of infection. Only a few patients felt that TCs offer no advantages. The patients' profiles and demographic data had no significant effect on their assessments of teleconsultations. Despite the overall positive rating given to TCs, patients unhesitatingly indicated that a face-to-face visit would be a preferable way to contact a specialist.

Utility and patient acceptance of telemedicine in nephrology

PURPOSE

There is an increasing burden of kidney diseases worldwide and access to specialist care is limited. Telemedicine, has been relatively less used in developing countries like India. The current study aims to assess the feasibility and acceptance of telenephrology services at our institute, a public hospital.

METHODS

A total of 150 patients were selected by stratified random sampling from the list of attendees who had undergone both in-person outpatient consultation and telenephrology consultation. Patient's attitude towards, and knowledge and acceptance of telenephrology services were evaluated.

RESULTS

The average age of the study cohort was 42.52 ± 15.1 years. More than one-third (39.3%) of our patients belonged to the lower middle socioeconomic class. The median distance traveled to reach our outpatient clinic was 113.5 km (3-2249 km). Patients reported lost workdays in 54.7% cases. The majority (95%) of patients managed to consult through teleservices successfully. Ninety percent of the patients gave a satisfaction score of 4 (out of 5) or above for their tele-consultation experience. The most important perceived benefit of teleconsultation was the reduced risk of infection (40.6%) followed by economic benefits (32%). The major disadvantage (36%) was the absence of physical examination. A combination of physical and telenephrology services was the option preferred by 84% of the patients.

CONCLUSION

In developing countries like India, with the majority of the population residing outside major cities and with limited medical access, telenephrology has a huge potential to provide quality nephrology care to the remotest parts of the country.

Protocol for a Multistage Mixed-Methods Evaluation of Multidisciplinary Chronic Kidney Disease Care Quality Following Integration of Virtual and In-Person Care During the COVID-19 Pandemic

Background

Multidisciplinary care of patients with chronic kidney disease (CKD) as it previously existed was predicated on an evidence and experience base of improved patient outcomes within an established and well-described service delivery model. The onset of the COVID-19 pandemic brought with it a departure from this established care delivery model toward integration of virtual care and in-person care.

Objective

To develop an evaluation framework to determine whether this shift in service delivery models has affected quality of multidisciplinary kidney care and/or patient-clinician interactions and relationships.

Design

A sequential multiphase, mixed-methods evaluation.

Setting

All 15 British Columbia (BC) multidisciplinary kidney care clinics (KCCs).

Participants

All patients and all clinicians in all KCCs across BC will be invited to participate in the planned evaluation.

Measurements

Qualitative and quantitative feedback from patients and families living with CKD and KCC clinicians.

Methods

The planned multiphase evaluation of virtual care integration in KCCs will be conducted across all 15 KCCs in the province of BC, Canada. The following phases are proposed: (1) review of current virtual care integration and practices, (2) assessment of patient and clinician experiences and perspectives via semi-structured interviews, (3) validation of those patient and clinician perspectives via survey of a larger sample, (4) compilation and analysis of all phases to provide informed recommendations for patient and visit format selection in a mixed in-person and virtual multidisciplinary clinic setting.

Limitations

This work will not capture any information about the relationship between differences in virtual usage parameters and clinical outcomes or financial implications.

Conclusions

There is no existing framework for either evaluation of multidisciplinary CKD care quality in a virtual setting or evaluation of care quality following a substantial change in service delivery models. The proposed evaluation protocol will enable better understanding of the nuances in kidney care delivery in this new format and inform how best to optimize the integration of virtual and pre-existing formats into kidney clinic care delivery beyond the pandemic. Beyond the current evaluation, this protocol may be of use for other jurisdictions to evaluate their own local instances of virtual care implementation and integration. The model may be adapted to evaluate quality of multidisciplinary kidney care delivery following other changes to clinic service delivery models.

Challenges of Antimicrobial Resistance and Stewardship in Solid Organ Transplant Patients

Purpose of Review

Without effective antimicrobials, patients cannot undergo transplant surgery safely or sustain immunosuppressive therapy. This review examines the burden of antimicrobial resistance in solid organ transplant recipients and identifies opportunities for antimicrobial stewardship.

Recent Findings

Antimicrobial resistance has been identified to be the leading cause of death globally. Multidrug-resistant pathogens are associated with significant morbidity and mortality in transplant recipients. Methicillin-resistant S. aureus affects liver and lung recipients, causing bacteremia, pneumonia, and surgical site infections. Vancomycin-resistant enterococci is a nosocomial pathogen primarily causing bacteremia in liver recipients. Multidrug-resistant Gram-negative pathogens present urgent and serious threats to transplant recipients. Extended-spectrum beta-lactamase-producing E. coli and K. pneumoniae commonly cause bacteremia and intra-abdominal infections in liver and kidney recipients. Carbapenemase-producing Enterobacterales, mainly K. pneumoniae, are responsible for infections early-post transplant in liver, lung, kidney, and heart recipients. P. aeruginosa and A. baumannii continue to be critical threats. While there are new antimicrobial agents targeting resistant pathogens, judicious prescribing is crucial to minimize emerging resistance. The full implications of the COVID-19 global pandemic on antimicrobial resistance in transplant recipients remain to be understood. Currently, there are no established standards on the implementation of antimicrobial stewardship interventions, but strategies that leverage existing antimicrobial stewardship program structure while tailoring to the needs of transplant recipients may help to optimize antimicrobial use.

Summary

Clinicians caring for transplant recipients face unique challenges tackling emerging antimcirobial resistance. Coordinated antimicrobial stewardship interventions in collaboration with appropriate expertise in transplant and infectious diseases may mitigate against such threats.

A Quantitative and Qualitative Study on Patient and Physician Perceptions of Nephrology Telephone Consultation During COVID-19

BACKGROUND

COVID-19 required rapid adoption of virtual modalities to provide care for patients with a chronic disease. Care was initially provided by telephone, which has not been evaluated for its effectiveness by patients and providers. This study reports patients' and nephrologists' perceptions and preferences surrounding telephone consultation in a chronic kidney disease (CKD) clinic.

OBJECTIVE

To evaluate patient and physician perspectives on the key advantages and disadvantages of telephone consultations in a nephrology out-patient clinic setting.

DESIGN

Cross-sectional observational survey study.

SETTING

General nephrology clinic and a multidisciplinary kidney care clinic in London, Ontario, Canada.

PARTICIPANTS

Patients with CKD who were fluent in English and participated in at least one telephone consultation with a nephrologist during the COVID-19 pandemic.

METHODS AND MEASUREMENTS

Nephrologists' and participants' input facilitated the development of both patient and nephrologist surveys. Participants provided self-reported measures in 5 domains of satisfaction: user experience, technical quality, perceived effectiveness on well-being, perceived usefulness, and effect on interaction. Nephrologists provided self-reported measures within 6 categories: general experience, time management, medication changes, quality of care, job satisfaction, and challenges/strengths. Descriptive statistics were used to present data. Content analysis was performed on 2 open-ended responses.

RESULTS

Of the 372 participants recruited, 235 participated in the survey (63% response). In all, 79% of the participants were ≥65 years old and 91% were white. Telephone consultation was a comfortable experience for 68%, and 73% felt it to be a safer alternative during the pandemic. Although 65% perceived no changes to health care access, most reported spending less time and fewer resources on transit and parking. Disadvantages to telephone consultation included a lack of physical examination and reduced patient-physician rapport. Eleven of 14 nephrologists were surveyed, with most reporting confidence in the use of telephone consultation. Physician barriers to telephone consultation included challenges with communications and lack of technology to support telephone clinics.

LIMITATIONS

Our survey included a majority of older, white participants, which may not be generalizable to other participants particularly those of other ages and ethnicity.

CONCLUSION

Although both patients and nephrologists adapted to telephone consultations, there remain opportunities to further explore populations and situations that would be better facilitated with an in-person visit. Future research in virtual care will require measurement of health care outcomes and economics.

TRIAL REGISTRATION

Not applicable as this was a survey.

Perceptions of Telehealth vs In-Person Visits Among Older Adults With Advanced Kidney Disease, Care Partners, and Clinicians

Importance

Telehealth has been posited as a cost-effective means for improving access to care for persons with chronic conditions, including kidney disease. Perceptions of telehealth among older patients with chronic illness, their care partners, and clinicians are largely unknown but are critical to successful telehealth use and expansion efforts.

Objective

To identify patient, care partner, and nephrologists' perceptions of the patient-centeredness, benefits, drawbacks of telehealth compared to in-person visits.

Design, Setting, and Participants

This qualitative study used semistructured interviews conducted from August to December 2020 with purposively sampled patients (aged 70 years or older, chronic kidney disease stages 4 to 5), care partners, and clinicians in Boston, Massachusetts; Chicago, Illinois; Portland, Maine; and San Diego, California.

Main Outcomes and Measures

Participants described telehealth experiences, including factors contributing to and impeding engagement, satisfaction, and quality of care. Thematic analysis was used to analyze data.

Results

Of 60 interviews, 19 (32%) were with clinicians, 30 (50%) with patients, and 11 (18%) with care partners; 16 clinicians (84%) were nephrologists; 17 patient participants (43%) were non-Hispanic Black, and 38 (67%) were women. Four overarching themes characterized telehealth's benefits and drawbacks for patient-centered care among older, chronically ill adults: inconsistent quality of care, patient experience and engagement, loss of connection and mistrust (eg, challenges discussing bad news), and disparities with accessing telehealth. Although telehealth improved convenience and care partner engagement, participants expressed concerns about clinical effectiveness and limitations of virtual physical examinations and potentially widening disparities in access. Many participants shared concerns about harms to the patient-clinician relationship, limited ability to comfort patients in virtual settings, and reduced patient trust.

Conclusions and Relevance

Older patients, care partners, and kidney clinicians (ie, nephrologists and physician assistants) shared divergent views of patient-centered telehealth care, especially its clinical effectiveness, patient experience, access to care, and clinician-patient relationship. Understanding older patients' and kidney clinicians' perceptions of telehealth elucidate barriers that should be addressed to promote high-quality care and telehealth use.

Software-based Detection of Acute Rejection Changes in Face Transplant

BACKGROUND

 An objective, non-invasive method for redness detection during acute allograft rejection in face transplantation (FT) is lacking.

METHODS

 A retrospective cohort study was performed with 688 images of 7 patients with face transplant (range, 1 to 108 months post-transplant). Healthy controls were matched to donor age, sex, and had no prior facial procedures. Rejection state was confirmed via tissue biopsy. An image-analysis software developed alongside VicarVision (Amsterdam, Netherlands) was used to produce R, a measure of differences between detectable color and absolute red. R is inversely proportional to redness, where lower R values correspond to increased redness. Linear mixed models were used to study fixed effect of rejection state on R values. Estimated marginal means of fitted models were calculated for pairwise comparisons.

RESULTS

 Of 688 images, 175, 170, 202, and 141 images were attributable to Banff Grade 0,1,2, and 3, respectively. Estimated change in R value of facial allografts decreased with increasing Banff Grade (p = 0.0001). The mean R value of clinical rejection (Banff Grade ⅔) (16.67, 95% Confidence Interval [CI] 14.79-18.58) was lower (p = 0.005) than non-rejection (Banff Grade 0/1) (19.38, 95%CI 17.43-21.33). Both clinical and non-rejection mean R values were lower (p = 0.0001) than healthy controls (24.12, 95%CI 20.96-27.28).

CONCLUSION

 This proof-of-concept study demonstrates that software-based analysis can detect and monitor acute rejection changes in FT. Future studies should expand on this tool's potential application in telehealth and as a screening tool for allograft rejection.