Looking beyond Mortality in Transplantation Outcomes

Elements of Post-Transplant Recovery in Lung Transplant Recipients: A Scoping Review

To clarify and refine the specific elements of post-transplant recovery in lung transplant recipients, we explored the four dimensions of recovery: physiological, psychological, social, and habitual. This study is a scoping review. Two authors conducted a comprehensive electronic literature search to identify studies published from the establishment of the database to August 2022. Deductive coding was utilized to identify and categorize elements using a predefined list of the four components (physiological, psychological, social, and habitual recovery) based on the framework of post-transplant recovery proposed by Lundmark et al. Inductive coding was applied for concepts requiring further classification. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guideline. Systematic searching identified 8,616 potential records, of which 51 studies met the inclusion criteria. Ten subdimensions and their corresponding elements were identified and categorized into four dimensions of recovery following lung transplantation. The subdimensions included physiological recovery (including symptom experience, complications, physical function, and energy reserve), psychological recovery (encompassing affective distress, psychological adaptation, and transition from illness to health), social recovery (involving family adaptation and social adaptation), and habit recovery (focusing on health behavior).

Kidney Transplant Clinicians' Perceptions of Palliative Care for Patients With Failing Allografts in the US: A Mixed Methods Study

RATIONALE & OBJECTIVE

Kidney transplant patients with failing allografts have a physical and psychological symptom burden as well as high morbidity and mortality. Palliative care is underutilized in this vulnerable population. We described kidney transplant clinicians' perceptions of palliative care to delineate their perceived barriers to and facilitators of providing palliative care to this population.

STUDY DESIGN

National explanatory sequential mixed methods study including an online survey and semistructured interviews.

SETTING & PARTICIPANTS

Kidney transplant clinicians in the United States surveyed and interviewed from October 2021 to March 2022.

ANALYTICAL APPROACH

Descriptive summary of survey responses, thematic analysis of qualitative interviews, and mixed methods integration of data.

RESULTS

A total of 149 clinicians completed the survey, and 19 completed the subsequent interviews. Over 90% of respondents agreed that palliative care can be helpful for patients with a failing kidney allograft. However, 46% of respondents disagreed that all patients with failing allografts benefit from palliative care, and two-thirds thought that patients would not want serious illness conversations. More than 90% of clinicians expressed concern that transplant patients and caregivers would feel scared or anxious if offered palliative care. The interviews identified three main themes: (1) transplant clinicians' unique sense of personal and professional responsibility was a barrier to palliative care engagement, (2) clinicians' uncertainty regarding the timing of palliative care collaboration would lead to delayed referral, and (3) clinicians felt challenged by factors related to patients' cultural backgrounds and identities, such as language differences. Many comments reflected an unfamiliarity with the broad scope of palliative care beyond end-of-life care.

LIMITATIONS

Potential selection bias.

CONCLUSIONS

Our study suggests that multiple barriers related to patients, clinicians, health systems, and health policies may pose challenges to the delivery of palliative care for patients with failing kidney transplants. This study illustrates the urgent need for ongoing efforts to optimize palliative care delivery models dedicated to kidney transplant patients, their families, and the clinicians who serve them.

PLAIN-LANGUAGE SUMMARY

Kidney transplant patients experience physical and psychological suffering in the context of their illnesses that may be amenable to palliative care. However, palliative care is often underutilized in this population. In this mixed-methods study, we surveyed 149 clinicians across the United States, and 19 of them completed semistructured interviews. Our study results demonstrate that several patient, clinician, system, and policy factors need to be addressed to improve palliative care delivery to this vulnerable population.

Conservative Kidney Management in Kidney Transplant Populations

Conservative kidney management (CKM) has been increasingly accepted as a therapeutic option for seriously ill patients with advanced chronic kidney disease. CKM is active medical management of advanced chronic kidney disease without dialysis, with a focus on delaying the worsening of kidney disease and minimizing symptom burden. CKM may be considered a suitable option for kidney transplant recipients with poorly functioning and declining allografts, defined as patients with low estimated glomerular filtration rate (<20 mL/min per 1.73 m2) who are approaching allograft failure. CKM may be a fitting option for transplant patients facing high morbidity and mortality with or without dialysis resumption, and it should be offered as a choice for this patient population. In this review, we describe clinical considerations in caring for patients with poorly functioning and declining kidney allografts, especially the unique decision-making process around kidney replacement therapies. We discuss ways to incorporate CKM as an option for these patients. We also discuss financial and policy considerations in providing CKM for this population. Patients with poorly functioning and declining kidney allografts should be supported throughout transitions of care by an interprofessional and multidisciplinary team attuned to their unique challenges. Further research on when, who, and how to integrate CKM into existing care structures for patients with poorly functioning and declining kidney allografts is needed.

Health-Related Quality of Life Outcomes Following Single or Bilateral Lung Transplantation: A Systematic Review

BACKGROUND

Lung transplantation is the definitive treatment for end-stage lung disease. There has been uncertainty regarding whether single or bilateral lung transplantation confers patients' greater health-related quality of life. This systematic review was performed to evaluate the impact of single lung transplantation (SLTx) against bilateral lung transplantation on short- and long-term health-related quality of life.

METHODS

A literature search was conducted on PubMed for studies matching the eligibility criteria between January 2000 and January 2022. OVID (MEDLINE), Google Scholar, EBSCOhost (EMBASE), and bibliographies of included studies were reviewed. Inclusion of studies was based on predetermined eligibility criteria. Quality appraisal and data tabulation were performed using predetermined forms. Results were synthesized by narrative review. The structure of this systematic review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. This systematic review was prospectively registered in the PROSPERO register (CRD42022344389).

RESULTS

Ten studies (1916 patients) were included. Within 12 mo posttransplantation, there was no evidence of the improved health-related quality of life with respect to the type of lung transplantation procedure. Bilateral lung transplantation patients reported significantly greater scores in both the physical and mental health domains of health-related quality of life. Bilateral lung transplantation offered significantly better health-related quality of life outcomes at later follow-up periods. Bilateral lung transplantation showed a significantly slower reduction in health-related quality of life physical composite scores relative to SLTx.

CONCLUSION

Bilateral lung transplant (BLTx) recipients perceive the greater health-related quality of life beyond 1-y post-lung transplantation. BLTx recipients better retain their health-related quality of life long-term posttransplantation than those receiving SLTx.

Top Ten Tips Palliative Care Clinicians Should Know About Solid Organ Transplantation

Solid organ transplantation (SOT) is a life-saving procedure for people with end-stage organ failure. However, patients experience significant symptom burden, complex decision making, morbidity, and mortality during both pre- and post-transplant periods. Palliative care (PC) is well suited and historically underdelivered for the transplant population. This article, written by a team of transplant specialists (surgeons, cardiologists, nephrologists, hepatologists, and pulmonologists), PC clinicians, and an ethics specialist, shares 10 high-yield tips for PC clinicians to consider when caring for SOT patients.

Predictors of death and new disability after critical illness: a multicentre prospective cohort study

PURPOSE

This study aimed to determine the prevalence and predictors of death or new disability following critical illness.

METHODS

Prospective, multicentre cohort study conducted in six metropolitan intensive care units (ICU). Participants were adults admitted to the ICU who received more than 24 h of mechanical ventilation. The primary outcome was death or new disability at 6 months, with new disability defined by a 10% increase in the WHODAS 2.0.

RESULTS

Of 628 patients with the primary outcome available (median age of 62 [49-71] years, 379 [61.0%] had a medical admission and 370 (58.9%) died or developed new disability by 6 months. Independent predictors of death or new disability included age [OR 1.02 (1.01-1.03), P = 0.001], higher severity of illness (APACHE III) [OR 1.02 (1.01-1.03), P < 0.001] and admission diagnosis. Compared to patients with a surgical admission diagnosis, patients with a cardiac arrest [OR (95% CI) 4.06 (1.89-8.68), P < 0.001], sepsis [OR (95% CI) 2.43 (1.32-4.47), P = 0.004], or trauma [OR (95% CI) 6.24 (3.07-12.71), P < 0.001] diagnosis had higher odds of death or new disability, while patients with a lung transplant [OR (95% CI) 0.21 (0.07-0.58), P = 0.003] diagnosis had lower odds. A model including these three variables had good calibration (Brier score 0.20) and acceptable discriminative power with an area under the receiver operating characteristic curve of 0.76 (95% CI 0.72-0.80).

CONCLUSION

Less than half of all patients mechanically ventilated for more than 24 h were alive and free of new disability at 6 months after admission to ICU. A model including age, illness severity and admission diagnosis has acceptable discriminative ability to predict death or new disability at 6 months.

Pre-transplantation Risks and Transplant-Techniques in Haematopoietic Stem Cell Transplantation for Acute Leukaemia

BACKGROUND

The role of conditioning intensity and stem cell source on modifying pre-transplantation risk in allogeneic haematopoietic stem cell transplantation (HSCT) is a matter of debate, but crucial when benchmarking centres.

METHODS

This Retrospective, multicenter exploratory-validation analysis of 9103 patients, (55.5% male, median age 50 years; 1-75 years range) with an allogeneic HSCT between 2010 and 2016 from a matched sibling (N = 8641; 95%) or matched unrelated donor (N = 462; 5%) for acute myeloid (N = 6432; 71%) or acute lymphoblastic (N = 2671; 29%) leukaemia in first complete remission, and reported by 240 centres in 30 countries to the benchmark database of the European Society for Blood and Marrow Transplantation (EBMT) searched for factors associated with use of transplant techniques (standard N = 6375;70% or reduced intensity conditioning N = 2728;30%, respectively bone marrow N = 1945;21% or peripheral blood N = 7158;79% as stem cell source), and their impact on outcome.

FINDINGS

Treatment groups differed significantly from baseline population (p < 0.001), and within groups regarding patient-, disease-, donor-, and centre-related pre-transplantation risk factors (p < 0.001); choice of technique did depend on pre-transplantation risk factors and centre (p < 0.001). Probability of overall survival at 5 years decreased systematically and significantly with increasing pre-transplantation risk score (score 2 vs 0/1 HR: 1·2, 95% c.i. [1·1-1·.3], p = 0.002; score 3 vs 0/1 HR: 1·5, 95% c.i. [1·3-1·7], p < 0.001; score 4/5/6 vs 0/1 HR: 1·9, 95% c.i. [1·6-2·2], p < 0.001) with no significant differences between treatment groups (likelihood ratio test on interaction: p = 0.40). Overall survival was significantly associated with selection steps and completeness of information (p < 0.001).

INTERPRETATION

Patients' pre-transplantation risk factors determine survival, independent of transplant techniques. Transplant techniques should be regarded as centre policy, not stratification factor in benchmarking. Selection criteria and completeness of data bias outcome. Outcomes may be improved more effectively through better identifying pre-transplantation factors as opposed to refinement of transplant techniques.

FUNDING

The study was funded by EBMT.

Noteworthy Literature Published in 2018 for Thoracic Organ Transplantation

Publications of note from 2018 are reviewed for the cardiothoracic transplant anesthesiologist. Strategies to expand the availability of donor organs were highlighted, including improved donor management, accumulating experience with increased-risk donors, ex vivo perfusion techniques, and donation after cardiac death. A number of reports examined posttransplant outcomes, including outcomes other than mortality, with new data-driven risk models. Use of extracorporeal support in cardiothoracic transplantation was a prominent theme. Major changes in adult heart allocation criteria were implemented, aiming to improve objectivity and transparency in the listing process. Frailty and prehabilitation emerged as targets of comprehensive perioperative risk mitigation programs.