Pretransplant predictors of posttransplant adherence and clinical outcome: an evidence base for pretransplant psychosocial screening. Transplantation. 2009;87:1497-1504. [PMID: 19461486 DOI: 10.1097/TP.0b013e3181a440ae]

The Equitable Benefit Approach to guide the assessment of medical and psychosocial factors in liver transplant candidacy

Lack of available organs poses a significant challenge in meeting the needs of patients with life-threatening liver disease who could benefit from liver transplantation (LT). Psychosocial vulnerability markers have been linked to post-transplant outcomes, raising questions about their use in patient selection. However, their incorporation into selection criteria raises concerns about health equity and potential discrimination. As a result, there is a pressing need to refine fair allocation systems that consider both clinical and psychosocial factors to ensure equitable access and optimize post-transplant outcomes. The Equitable Benefit Approach (EBA) proposed in this paper by the multidisciplinary group of clinical experts in LT from the Italian Society for the Study of the Liver seeks to address these concerns. It presents four procedural principles, the two allocative principles usually applied in transplantation (urgency and utility) and introduces a new one, the principle of health equity. The EBA aims to prioritize patients with the highest transplant benefit while addressing health inequalities. It emphasizes evidence-based decision-making and standardized assessment tools to reliably evaluate psychosocial risk factors. Implementing the EBA involves a multi-step process, including stakeholder engagement, prospective studies to validate its efficacy, development of institutional policies and algorithms, and ongoing monitoring and revision. By following these steps, health care providers can ensure that LT allocation decisions are transparent and responsive to evolving clinical and social contexts. Ultimately, the EBA should offer a comprehensive framework for fair patient selection in LT, considering both biomedical and psychosocial aspects.

Lung transplant recipients' experiences of and attitudes towards self-management: a qualitative systematic review

OBJECTIVE

The objective of this review was to identify lung transplant recipients' experiences of and attitudes towards self-management.

INTRODUCTION

Lung transplantation is an established treatment to improve the survival of patients with end-stage lung diseases and has been performed on over 40,000 patients worldwide. The current focus of care for lung transplant recipients is on their long-term management. Patients need to adapt and adhere to complex self-management tasks to prevent complications and to enable them to keep the transplanted graft as long as possible. However, to date, no qualitative systematic review exists that identifies lung transplant recipients' experiences of and attitudes towards self-management.

INCLUSION CRITERIA

This review included adults over 18 years of age who had received a lung transplant and were able to perform their self-management tasks independently. All studies that investigated lung transplant recipients' experiences of and attitudes towards self-management in any setting were included in this review. All types of studies that focused on qualitative data, including, but not limited to, phenomenology, grounded theory, ethnography, action research, and feminist research were considered for inclusion. Mixed methods studies were included only when qualitative data could be extracted separately, and if they reported results relating to the phenomena of interest. Studies published in English or German were considered for inclusion in this review.

METHODS

The search strategy aimed to find published studies from 6 databases from the database inception to March 2022. Methodological quality of studies was independently assessed by 2 independent reviewers using the JBI checklist for qualitative research. A standardized data extraction tool from JBI was used by 2 reviewers for data collection. Meta-aggregation was undertaken to synthesize the data, and the final synthesis of the findings was reached through discussion. Results were graded according to ConQual.

RESULTS

Ten studies with a sample size from 8 to 73 participants from North America and Central/Northern Europe were included in the review. The critical appraisal scores of the included studies varied from 3 to 9 out of 10. A total of 137 findings were extracted and aggregated to form 19 categories and the following 4 aggregated syntheses: i) Changes in routines, beliefs, and sense of responsibility are essential for better adaptation and self-management after lung transplantation; ii) Life after transplantation is characterized by both positive and negative feelings and experiences; iii) Better adjustment and self-management after a lung transplant require dealing with one's own feelings and beliefs; iv) After transplantation, engaging with relatives, friends, medical team and donors is essential to improve experiences and adapt to being a transplant recipient. Based on the ConQual scores, 2 synthesized findings were graded as moderate and 2 as low.

CONCLUSIONS

Nuanced emotional, social, relational, and psychological adjustment is required of lung transplant recipients to be able to successfully self-manage. Loved ones and health professionals contribute significantly to this process, but psychosocial or peer support may further facilitate this transition.

SUPPLEMENTAL DIGITAL CONTENT

A German-language version of the abstract of this review is available as Supplemental Digital Content [http://links.lww.com/SRX/A46].

Demographic Factors, Medication Adherence, and Post-transplant Health Outcomes: A Longitudinal Multilevel Modeling Approach

Few studies in pediatric solid organ transplantation have examined non-adherence to immunosuppressive medication over time and its associations with demographic factors and post-transplant outcomes including late acute rejection and hospitalizations. We examined longitudinal variation in patient Medication Level Variability Index (MLVI) adherence data from pediatric kidney, liver, and heart transplant recipients. Patient and administrative data from the United Network for Organ Sharing were linked with electronic health records and MLVI values for 332 patients. Multilevel mediation modeling indicated comparatively more variation in MLVI values between patients than within patients, longitudinally, over 10 years post transplant. MLVI values significantly predicted late acute rejection and hospitalization. MLVI partially mediated patient factors and post-transplant outcomes for patient age indicating adolescents may benefit most from intervention efforts. Results demonstrate the importance of longitudinal assessment of adherence and differences among patients. Efforts to promote medication adherence should be adapted to high-risk patients to increase likelihood of adherence.

Applications of motivational interviewing in adolescent solid organ transplant

BACKGROUND

Adolescence is a developmental period that is known for the highest risk of difficulties with adoption and maintenance of health behaviors for successful transplant. Motivational interviewing (MI) has been demonstrated to be an effective strategy in the management of modifiable factors impacting adherence in both adult transplant and analogous pediatric chronic illness populations.

AIMS

This paper describes MI and its applicability to adolescent transplant, providing examples of its potential use at each stage of the transplant journey.

MATERIALS AND METHODS

Literature on the principles and utilization of MI are reviewed, as well as the use of MI in adult transplant and similar pediatric populations.

RESULTS

Evidence suggests high applicability of concepts of MI to pediatric transplant.

DISCUSSION

Systems-level factors influencing health behavior change are discussed, along with the importance of recognizing and managing provider bias in MI-based interactions. MI does not require a licensed behavioral health provider to use it effectively; rather, it can be used by various multidisciplinary team members throughout the course of clinical care.

CONCLUSION

MI shows great promise as a useful intervention through all stages in the transplant journey. Though particularly well-suited to adolescents, its principles are effective across the lifespan, including with caregivers. It represents an interactional style for use by multidisciplinary team members in many patient-and caregiver-facing scenarios. As the goal is to support the patient's autonomy in decision-making, it is important for providers to recognize their own biases. Further resources for training are provided.

Medication adherence in pediatric kidney transplantation: How to build a bridge over troubled water

Adhering to the immunosuppressive regimen remains one of the biggest challenges for children and adolescents after kidney transplantation. The first paper on nonadherence, co-authored by Dr. Fine, appeared in Pubmed over 45 years ago. Since then, many clinicians and researchers tried to better understand nonadherence and are looking for effective ways to support young people in implementing the complex medication regimen in their daily lives. As a tribute to Dr. Fine, we conducted a comprehensive review providing an overview of adherence-enhancing interventions in the field of pediatric kidney transplantation, thereby focusing on strategies that not only are effective but can also be embedded in daily clinical practice successfully and sustainably. This overview is preceded by a discussion about how to find out who is in need of supportive interventions. We will also argue that interventions should already start before pediatric kidney transplantation and discuss how to decide whether or not a young patient with nonadherence-induced graft loss should undergo retransplantation. We hope this comprehensive overview will rekindle the hope that we can finally turn the tide and beat one of pediatric kidney transplantation's main enemies.

Association of the Stanford Integrated Psychosocial Assessment for Transplant and 1-Year Outcome of Living Kidney Transplantation in Japan

BACKGROUND

Because most kidney transplantations in Japan are performed on the basis of living donors, after-transplant outcomes should achieve optimum results, overcoming participants' possible reduced adherence.

OBJECTIVE

To investigate the association between the Japanese version of the Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT-J) and outcomes, 1 year after the patient's living kidney transplant (LKT).

METHODS

The prospective cohort study was undertaken at Tokyo Women's Medical University Hospital from January 2020 to July 2021, with a 1-year follow-up period. The SIPAT-J assesses 18 psychosocial risk factors: (1) Patient's Readiness Level and Illness Management (SIPAT A), (2) Social Support System Level of Readiness (SIPAT B), (3) Psychological Stability and Psychopathology (SIPAT C), and (4) Lifestyle and Effect of Substance Use (SIPAT D). The evaluators, a psychiatrist and 3 clinical psychologists, conducted an independent, blinded application of the SIPAT-J using participants' medical records. The study focused on physical composite outcomes, psychiatric outcomes, and nonadherent behaviors.

RESULTS

The participants were 173 LKT recipients (median age [interquartile range], 51 [38-59]); 67.1% were male and 67.1% were employed. The median (interquartile range) SIPAT scores were SIPAT A [7 (5-9)], SIPAT B [7 (5-9)], SIPAT C [2 (0-4)], SIPAT D [3 (3-4)], and SIPAT total [20 (16-23)]. The physical composite outcome was 25 (14.5%), psychiatric outcome 9 (5.2%), and nonadherent behavior 17 (9.8%). SIPAT C (odds ratio = 1.34, 95% confidence interval = 1.06-1.72, P = 0.02) was significantly associated with the psychiatric outcome. SIPAT B (odds ratio = 1.49, 95% confidence interval = 1.12-1.98, P = 0.01) and SIPAT total (odds ratio = 1.13, 95% confidence interval = 1.03-1.24, P = 0.01) were significantly associated with nonadherent behaviors. There was no significant association between the SIPAT and physical composite outcomes.

CONCLUSION

This study is the first to examine the association between SIPAT and physical and psychiatric outcomes 1 year after LKT, controlling for follow-up periods and factors other than SIPAT. Comprehensive psychosocial assessment before LKT and early identification of factors that may negatively affect transplant success can allow targeted interventions to be implemented and increase the likelihood of favorable recipient outcomes.

Higher-risk SIPAT score predicts increased risk of long-term mortality in orthotopic heart transplant recipients

BACKGROUND

Orthotopic heart transplantation (OHT) improves survival in eligible patients. Organ scarcity necessitates extensive clinical and psychosocial evaluations before listing. The Stanford Integrated Psychosocial Assessment for Transplant (SIPAT) predicts risk for poor psychosocial outcomes and morbidity in the first year post-transplant, yet it is unknown whether it predicts long-term outcomes.

METHODS

Blinded examiners obtained data from a retrospective cohort of 51 OHT recipients from a high-volume center. Patients with "Excellent" or "Good" SIPAT score indicating low psychosocial risk for transplant (E/G) were compared with those who met "Minimum Acceptable Criteria" or were "High Risk" (MAC/HR). Associations were examined between SIPAT group and outcomes.

RESULTS

MAC/HR versus E/G recipients had significantly reduced survival in the 10 years post-OHT (mean 6.7 vs 8.8 years, p = 0.027; 55% vs 82% survival proportions, p = 0.037). MAC/HR patients were more likely to live in a county with greater income inequality (p = 0.025) and have psychiatric history pre-OHT (p = 0.046). Both groups had otherwise similar demographics and medical history. A lower proportion of MAC/HR patients adhered to medications post-OHT and a greater proportion had psychiatric illness, though differences were not significant.

CONCLUSIONS

Higher-risk SIPAT scores predict reduced long-term survival post-OHT. Further efforts are crucial to improve outcomes in higher-risk patients.

Interventions to support adolescents and young adults with the healthcare transition from paediatric to adult nephrology health services: A scoping review protocol

Background

Due to technological advancements and improved medical management of adolescents and young adults (AYAs) living with renal disease, there has been an exponential increase noted in the number of patients advancing from the paediatric to the adult nephrology healthcare setting. Subsequently, more AYAs are required to undergo the process of healthcare transition from paediatric to adult healthcare services. This process can be a challenging period for young people and families and is often associated with a decline in physical and psychosocial health outcomes of AYAs with renal disorders. To ensure a successful transition, AYAs must develop the ability to manage their renal condition, including the medical and psychosocial aspects of their condition, independently. Despite significant research into the transition from paediatric to adult healthcare for this unique patient cohort, the transition period remains a challenge at times. This scoping review aims to map, explore, and understand the interventions that are currently available to offer positive perceptions and experiences of transition for both AYAs living with renal disorders and their families.

Methods

A systematic literature search will be conducted of PubMed, PsycInfo, CINAHL, ASSIA, EMBASE and Web of Science databases from the year 2000 to present. Two independent reviewers will screen the peer-reviewed literature obtained and assess them against the inclusion criteria to determine their inclusion eligibility. Data will be extracted and synthesised using a template refined by the authors. The scoping review will be undertaken in accordance with PRISMA-ScR guidelines. Data will undergo a formal critical appraisal using recognised appraisal tools.

Conclusions

Through mapping this knowledge, the scoping review will aim to identify interventions that are currently available and identify gaps within the literature. This evidence may support the development of transitional care interventions in the future, promote patient satisfaction, and improve patient outcome measures and experiences.

Development and validation of a LASSO-based prediction model for immunosuppressive medication nonadherence in kidney transplant recipients

INTRODUCTION

To establish a prediction model to predict immunosuppressive medication (IM) nonadherence in kidney transplant recipients (KTRs) based on a combined theory framework.

METHODS

This polycentric, cross-sectional study included 1191 KTRs from October 2020 to February 2021 in China, with 1011 KTRs enrolled in the derivation set and 180 in the external validation set. Variables selected based on the combined theory of planned behavior (TPB)/health belief model (HBM) theory were analyzed by the least absolute shrinkage and selection operator (LASSO). Internal 10 cross-validation was conducted to determine the optimal lambda value. The receiver operating characteristic (ROC) curve, specificity, and sensitivity were used to evaluate the prediction model, and further assessment was run by external validation.

RESULTS

IM nonadherence rate was 38.48% in the derivation set and 37.22% in the validation set. The LASSO model was developed with eight predictors for IM nonadherence: age, preoperative drinking history, education, marital status, perceived barriers, social support, perceived behavioral control, and perceived susceptibility. The model demonstrated acceptable discrimination with the area under the ROC curve of 0.797 (95% CI: 0.745-0.850) in the internal validation set and 0.757 (95% CI: 0.684-0.829) in the external validation set. The specificity and sensitivity in the internal validation and external validation set were 0.741, 0.748, 0.673, and 0.716, respectively.

CONCLUSIONS

The LASSO model was developed to guide identifying high-risk nonadherent patients and timely and effective interventions to improve their prognosis and survival.

Characterization of the stanford integrated psychosocial assessment for transplant for heart, liver, and kidney transplant candidates in Japan

BACKGROUND

The Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) is a comprehensive psychosocial assessment proven useful for predicting the outcomes of organ transplantation that is expected to be useful in Japan. However, the characteristics of organ-specific SIPAT scores for organ transplant recipient candidates in Japan are unclear and, to date, the SIPAT has not been properly utilized in clinical practice. The purpose of this study was to present basic data that can be used to establish the relation between SIPAT scores and post-transplantation psychosocial outcomes as well as organ-specific outcomes.

METHODS

This study included 167 transplant recipient candidates (25 heart, 71 liver, and 71 kidney) who completed a semi-structured interview based on the Japanese version of SIPAT (SIPAT-J) prior to transplantation. The differences between organs in terms of SIPAT scores and differences in SIPAT scores based on demographic data were comparatively analyzed.

RESULTS

The total SIPAT scores were higher for liver recipient candidates than for heart recipient candidates (P = .019). Regarding the subscales, SIPAT B (social support system) scores were higher for liver and kidney recipient candidates than for heart recipient candidates (P = .021), whereas SIPAT C (psychological stability and psychopathology) scores were higher for liver recipient candidates than for kidney recipient candidates (P = .002). Recipient candidates with a history of psychiatric treatment and those who were unemployed had higher SIPAT scores, regardless of the transplant organ, than recipient candidates without a history of psychiatric treatment and those who were employed (P < .001, P = .016, respectively).

CONCLUSIONS

There were notable differences in the total SIPAT-J and subscale scores among the liver, heart, and kidney recipient candidates. Each organ was associated with specific psychosocial issues that should be addressed before transplantation. Interventions such as information provision and patient education based on SIPAT assessment results for each organ may improve recipient post-transplant outcomes.

Post-liver transplantation patient experience

Given improvements in post-transplant patient and graft survival, there is a growing need to focus on patient experience and health-related quality of life (HRQOL). Though liver transplantation can be life-saving, it can also be associated with significant morbidity and complications. Patient HRQOL improves after transplantation, but it may not improve to that of age-matched cohorts. Understanding patient experience and the factors that contribute to it, including physical and psychological health, immunosuppression and medication adherence, return to employment or school, financial burden, and expectations, helps when thinking creatively about potential interventions to improve HRQOL.

Predicting psychosocial risk in pediatric kidney transplantation: An exploratory cluster analysis of a revised Pediatric Transplant Rating Instrument

BACKGROUND

The Pediatric Transplant Rating Instrument (P-TRI) is a 17-item scale developed to assess psychosocial risk factors for poor outcomes after solid organ transplantation. Research has identified the limitations of the original instrument and proposed revisions to improve clinical utility. This project examined patterns of risk in children being evaluated for kidney transplant using a revised P-TRI.

METHODS

A multidisciplinary kidney transplant team revised the P-TRI. A social worker and a psychologist collaboratively completed the modified instrument for 37 children after the psychosocial pretransplant evaluation. Electronic medical records were reviewed for transplant status (transplanted, active waitlist, inactive) 1 year later. Exploratory cluster analyses and chi-square tests examined patterns of risk and correlates with cluster membership.

RESULTS

Three clusters were identified. The high-risk group (29.7%) had difficulties with medication and appointment adherence, strained relationships with the medical team, and the presence of parent psychiatric history. The medium-risk group (35.1%) had difficulties with parent knowledge, financial strain, and risk factors for medication nonadherence. The low-risk group (35.1%) demonstrated no difficulties with adherence or financial strain. Clusters were prospectively associated with transplant status, such that those in the high-risk group were less likely to be transplanted within 1 year post-evaluation.

CONCLUSIONS

The revised P-TRI demonstrated good construct validity as risk level appeared to be associated with transplant listing status 1 year post-evaluation. These results suggest that standardized pretransplant psychosocial risk assessment tools may have value in optimizing transplant access if they can be paired with targeted, multidisciplinary interventions to address concerns early in the transplant process.

[Follow-up strategies for lung transplant recipients in France]

BACKGROUND

Lung transplantation (LT) requires sustained care for a frequently polypathological condition. Follow-up is focused on three main issues: 1/stability of respiratory function; 2/comorbidity management; 3/preventive medicine. About 3000 LT patients in France are treated in 11 LT centers. Given the increased size of the LT recipient cohort, follow-up might be partially shared with peripheral centers.

METHODS

This paper presents the suggestions of a working group of the SPLF (French-speaking respiratory medicine society) on possible modalities of shared follow-up.

RESULTS

While the main LT center is tasked with centralizing follow-up, particularly the choice of optimal immunosuppression, an identified peripheral center (PC) may serve as an alternative to deal with acute events, comorbidities and routine assessment. Communication between the different centers should be free-flowing. Shared follow-up may be offered from the 3rd postoperative year to stable and consenting patients, whereas unstable and non-observant patients are poor candidates.

CONCLUSION

These guidelines may serve as a reference for any pneumologist wishing to effectively contribute to follow-up, even and especially subsequent to lung transplant.

Psychosocial predictors in upper-extremity vascularized composite allotransplantation: A qualitative study of multidimensional experiences including patients, healthcare professionals, and close relatives

Background

The impact of patient-specific psychosocial factors on functional outcomes after upper-extremity (UE) vascularized composite allotransplantation (VCA) is poorly understood. The objective of this study was to identify relevant psychosocial predictors for success or failure of UE VCA in an Austrian cohort.

Methods

A qualitative study was undertaken consisting of semi-structured interviews with UE VCA staff, transplanted patients, and close relatives. Participants were asked about their perceptions of factors that either favored or hindered a successful transplant outcome, including functional status before surgery, preparation for transplant, decision-making, rehabilitation and functional outcome after surgery, and family and social support. Interviews were conducted online and recorded with the consent of interviewees.

Results

Four bilateral UE VCA patients, 7 healthcare professionals, and a sister of a patient participated in the study. Thematic analysis revealed the importance of an expert interdisciplinary team with adequate resources for patient selection. Psychosocial aspects of prospective candidates are crucial to evaluate as they contribute to success. Both patients and providers may be impacted by public perceptions of UE VCA. Functional outcomes are optimized with a life-long commitment to rehabilitation as well as close, ongoing provider involvement.

Conclusion

Psychosocial factors are important elements in the assessment and follow-up care for UE VCA. To best capture psychosocial elements of care, protocols must be individualized, patient-centered, and interdisciplinary. Investigating psychosocial predictors and collecting outcomes is, thus, critical to justifying UE VCA as a medical intervention and to providing accurate and salient information to prospective candidates.

Interventions to support adolescents and young adults with the healthcare transition from paediatric to adult nephrology health services: A scoping review protocol

Background: Due to technological advancements and improved medical management of adolescents and young adults (AYAs) living with renal disease, there has been an exponential increase noted in the number of patients advancing from the paediatric to adult nephrology healthcare setting. Subsequently, more AYAs are required to undergo the process of healthcare transition from paediatric to adult healthcare services. This process is often a challenging period for young people and families and is often associated with a decline in physical and psychosocial health outcomes of AYAs with renal disorders. To ensure a successful transition, AYAs must develop the ability to manage their renal condition, including the medical and psychosocial aspects of their condition, independently. Despite significant research into the transition from paediatric to adult healthcare for this unique patient cohort, the transition period remains a challenge. The scoping review will aim to map, explore, and understand the interventions that are currently available to offer positive perceptions and experiences of transition for both AYAs living with renal disorders and their families. Methods: A systematic literature search will be conducted of PubMed, PsycInfo, CINAHL, ASSIA, EMBASE and Web of Science databases from the year 2000 to present. Two independent reviewers will screen the title and abstracts of peer-reviewed literature obtained and assess them against the inclusion criteria to determine their inclusion eligibility. Data will be extracted and synthesised using a template refined by the authors. The scoping review will be undertaken in accordance with PRISMA-ScR guidelines. Data will undergo a formal critical appraisal using recognised appraisal tools. Conclusions: Through mapping this knowledge, the scoping review will aim to identify interventions that are currently available and identify gaps within the literature. This evidence may support the development of transitional care interventions in the future, promote patient satisfaction, and improve patient outcome measures and experiences.

Psychosocial Characteristics of Patients Evaluated for Kidney, Liver, or Heart Transplantation

OBJECTIVE

Psychosocial parameters play a pivotal role in organ recipient evaluation before wait-listing for transplantation because of their impact on organ and patient outcome. Patients in need of heart (HTx), liver (LTx), or kidney transplantation (KTx) face distinct physical and psychological challenges. This study compares the psychosocial characteristics and preferences for additional therapy for patients undergoing assessment for these three types of organ transplantation to optimize patient-tailored psychological, social, and other supportive interventions.

METHODS

We conducted a cross-sectional, observational study with 1110 potential transplantation candidates (LTx, n = 544; KTx, n = 330; HTx, n = 236), psychosocial status was determined for depressive symptoms (Patient Health Questionnaire Depression Scale), anxiety symptoms (seven-item Generalized Anxiety Disorder Screener), health-related quality of life (36-Item Short Form Health Survey), perceived social support (Perceived Social Support Questionnaire), sense of coherence (SoC; short form of the Sense of Coherence Scale), self-efficacy (General Self-Efficacy Short Scale), and body image (German Body Image Questionnaire-20). Preferences for additional supportive therapy were assessed dichotomously. Data were analyzed using multivariate analysis of covariance and χ2 tests.

RESULTS

Patient groups differed significantly regarding depression ( F (2,1107) = 35.283, p < .001, partial η2 = 0.01), anxiety ( F (2,1107) = 15.027, p < .001, partial η2 = 0.03), health-related quality of life (physical: F (2,1107) = 96.772, p < .001, partial η2 = 0.15; mental: F (2,1107) = 11.442, p < .001, partial η2 = 0.02), perceived social support ( F (2,1107) = 20.813, p < .001, partial η2 = 0.04), SoC ( F (2,1107) = 12.920, p < .001, partial η2 = 0.02), self-efficacy ( F (2,1107) = 17.308, p < .001, partial η2 = 0.03), and body image (rejecting body evaluation: F (2,1107) = 5.006, p = .007, partial η2 = 0.01; vital body dynamics: F (2,1107) = 40.216, p < .001, partial η2 = 0.07). Patients evaluated for HTx showed the highest psychosocial impairment and the highest inclination regarding additional supportive therapy.

CONCLUSIONS

Patients evaluated for HTx, LTx, and KTx have distinct psychosocial characteristics and treatment preferences. HTx patients display the highest psychosocial impairment. We suggest psychocardiological treatment structures for optimal outcome.

Reevaluating the Ethical Issues in Porcine-to-Human Heart Xenotransplantation

A major limiting factor with heart allotransplantation remains the availability of organs from deceased donors. Porcine heart xenotransplantation could serve as an alternative source of organs for patients with terminal heart failure. A first-in-human porcine xenotransplantation that occurred in January 2022 at the University of Maryland Medical Center provided an opportunity to examine several ethical issues to guide selection criteria for future xenotransplantation clinical trials. In this article, the authors, who are clinicians at UMMC, discuss the appropriate balancing of risks and benefits and the significance, if any, of clinical equipoise. The authors also review the alleged role of the psychosocial evaluation in identifying patients at an elevated risk of posttransplant noncompliance, and they consider how the evaluation's implementation might enhance inequities among diverse populations. The authors argue that, based on the principle of reciprocity, psychosocial criteria should be used, not to exclude patients, but instead to identify patients who need additional support. Finally, the authors discuss the requirements for and the proper assessment of informed and voluntary consent from patients being considered for xenotransplantation.

Indications for Lung Transplantation and Patient Selection

Globally, thousands of patients undergo lung transplantation owing to end-stage lung disease each year. As lung transplantation evolves, recommendations and indications are constantly being updated. In 2021, the International Society for Heart and Lung Transplantation published a new consensus document for selecting candidates for lung transplantation. However, it is still difficult to determine appropriate candidates for lung transplantation among patients with complex medical conditions and various diseases. Therefore, it is necessary to analyze each patient’s overall situation and medical condition from various perspectives, and ongoing efforts to optimize the analysis will be necessary. The purpose of this study is to review the extant literature and discuss recent updates.

The effects of demographic, psychosocial, and socioeconomic characteristics on access to heart transplantation and left ventricular assist device

Background

This study aims to better understand how demographic, psychosocial, and socioeconomic factors influence the selection of patients for advanced therapies for heart failure (heart transplant and left ventricular assist device (LVAD)).

Methods

Patients evaluated for heart transplant or LVAD at a large, Midwestern hospital system were assessed retrospectively. Three outcomes were analyzed: 1) Patients who were evaluated and approved to receive a transplant or LVAD were compared to patients who were not approved for transplant or LVAD; 2) Patients who were listed for transplant were compared to patients not listed; and 3) Patients who received a transplant or LVAD were compared to patients who did not receive a transplant or LVAD. ANOVA was used for continuous variables and Chi-squared test for categorical variables. Significant variables were further analyzed by logistic regression.

Results

Four hundred fifty-nine patients were included. Marital status (p = 0.004), race (p = 0.008), social support (p < 0.001), mental health (p = 0.006), and substance use (p < 0.001) were associated with whether patients were approved for transplant or LVAD. Patients with public insurance were half as likely (OR 0.495) to be listed for transplant once approved.

Conclusions

Financial, psychosocial, and demographic characteristics all play a role in selection for advanced therapies for heart failure. These insights can help guide future work on interventions to address the social disparities in access to heart transplant and LVAD.

The Association between Psychosocial and Age-Related Factors with Adherence to Immunosuppressive Therapies after Renal Transplantation

Renal transplantation (RT) is the optimal renal replacement treatment approach in terms of patient survival and high quality of life. Proper adherence to medication is essential in order to prolong graft life and patient survival. This study aimed to investigate the effects of psychosocial factors and age-related declines on adherence in kidney transplant recipients. Methods: This was a cross-sectional study of kidney transplant recipients, based on regression analysis. Patient adherence was assessed with the Basel Assessment of Adherence with Immunosuppressive Medication Scale (BAASIS). Psychosocial and age-related variables were measured with the World Health Organization’s quality of life questionnaire (WHOQoL-BREF), the Mini-Mental State Examination (MMSE), the Hospital Anxiety and Depression Scale (HADS), the Acceptance of Illness Scale (AIS), and the Tilburg Frailty Indicator (TFI). Results: A simple linear regression model indicated that the significant predictors of self-reported adherence (p < 0.05) were age, time since transplant, and anxiety and cognitive functions. For problems with implementing immunosuppressive medication, logistic regression models showed that gender, age, retirement status, hypercholesterolemia, and cognitive impairment were the most significant predictors (p < 0.05). However, after controlling for other predictors in the multiple regression models, anxiety and cognitive ability no longer predicted treatment adherence to immunosuppressive medication. Conclusions: Renal transplantation is the most effective therapy in chronic renal failure patients. Proper adherence to immunosuppressive therapy is critical to prolonging graft and person survival. Our study shows that occupational status more significantly influences adherence to the implementation of treatment in kidney transplant recipients.

Adherence to Immunosuppressive Medication in Iraqi Kidney Transplant Recipients During the First Year of Transplant. A Single-Center Experience

OBJECTIVES

Our objective was to measure adherence to immunosuppressive medications among Iraqi renal transplant patients at a single center.

MATERIALS AND METHODS

This cross-sectional study was conducted from January to November 2020 in the outpatient unit of the Nephrology and Renal Transplantation Center in Baghdad's Medical City. Seventy-five adult Iraqi renal transplant recipients were recruited. An Arabic version of the Basel Assessment of Adherence to Immunosuppressive Medications (BAASIS) scale was used to evaluate adherence.

RESULTS

The study included 75 adult renal transplant recipients (51 men/24 women) with a mean age of 39.44 ± 12.06 years. The mean time posttransplant was 8.11 ± 3.12 months. In our patient group, 65.33% reported total adherence and 34.6% did not adhere to one (25.3%) or more (9.3%) drug. We observed a statistically significant association between nonadherence and complications (P = .015, chi-square test). Four patients had biopsy-proven acute rejection, and all 4 patients were noncompliant with medications. Binary logistic regression model P values for employment, time after transplant, and complications were .06, .06, and .08, respectively.

CONCLUSIONS

There was a high rate of nonadherence among our sample of Iraqi renal transplant recipients in the first year posttransplant. Time after transplant and transplant complications were related to nonadherence. More extensive multicenter studies are needed to define the actual rate of adherence to immune suppression in Iraq.

Depression, Quantified Medication Adherence, and Quality of Life in Renal Transplant Candidates and Recipients

Like patients with many chronic illnesses, ESRD patients experience psychological challenges with greater incidence of depression and reduced quality of life (QoL). A series of 139 transplant candidates' depression and QoL, and a subset of 82 candidates' medication adherence were monitored, revealing heterogenous patterns of depression and adherence and reduced QoL. Twenty-eight patients who received kidney transplants were re-evaluated 6 months post-transplant revealing mixed patterns. Mean depression and quantitated adherence decreased and QoL increased. Some patients improved whereas others declined in depression and adherence. Pre-transplant depression was negatively correlated with post-transplant adherence but positively correlated with post-transplant depression. Nevertheless, the ability to predict individuals' post-transplant adherence and depression, principal objectives of pre-transplant psychological evaluations, is limited. Consequently, it is important to provide periodic screening of ESRD patients for depression and adherence pre- and post-transplant as they reflect changing states, rather than static traits, with variable patterns across patients.

Age at Time of Kidney Transplantation as a Predictor for Mortality, Graft Loss and Self-Rated Health Status: Results From the Swiss Transplant Cohort Study

Introduction: The effect of age on health outcomes in kidney transplantation remains inconclusive. This study aimed to analyze the relationship between age at time of kidney transplantation with mortality, graft loss and self-rated health status in adult kidney transplant recipients.

Methods: This study used data from the Swiss Transplant Cohort Study and included prospective data of kidney transplant recipients between 2008 and 2017. Time-to-event analysis was performed using Cox’ regression analysis, and -in the case of graft loss- competing risk analysis. A random-intercept regression model was applied to analyse self-rated health status.

Results: We included 2,366 kidney transplant recipients. Age at transplantation linearly predicted mortality. It was also predictive for graft loss, though nonlinearly, showing that recipients aged between 35 and 55 years presented with the lowest risk of experiencing graft loss. No relationship of age with self-rated health status was detected.

Conclusion: Higher mortality in older recipients complies with data from the general population. The non-linear relationship between age and graft loss and the higher scored self-rated health status at all follow-up time-points compared to the pre-transplant status -regardless of age- highlight that age alone might not be an accurate measure for risk prediction and clinical decision making in kidney transplantation.

Psychosocial Evaluation in Liver Transplantation for Patients with Alcohol-Related Liver Disease

Content available: Author Interview and Audio Recording.

Association of race and gender with primary caregiver relationships and eligibility for advanced heart failure therapies

BACKGROUND

Caregiver support is considered necessary after heart transplant (HT) and left ventricular assist device (LVAD) for patients with end-stage heart failure (HF). Few studies have demonstrated how caregivers differ by gender and race, and whether that impacts therapy eligibility.

METHODS

We examined caregiver relationships among 674 patients (32% women, 55% Black) evaluated at Emory University from 2011 to 2017. Therapy readiness was assessed using the Stanford Integrated Assessment for Transplant (SIPAT). Evaluation outcome according to caregiver relationship was compared using χ² analysis. Multivariable logistic regression determined the association between caregiver and eligibility according to gender and race.

RESULTS

Women and Black patients were less likely to have spouses as their support person (P < .001). Women were less likely to be considered eligible for advanced therapies (adjusted odds ratio [aOR] .64, 95% confidence interval [CI] .46-.89; P = .008), with Black women having lower eligibility than White women (aOR .28, 95% CI .11-.72; P = .008). Social support and SIPAT scores did not significantly influence eligibility by gender or race.

CONCLUSION

Lack of caregiver support is considered a relative contraindication to advanced therapies. Type of caregiver in our cohort varied according to race and gender but did not explain differences in eligibility for advanced therapies.

Chronic Kidney Disease and Its Relationship with Mental Health: Allostatic Load Perspective for Integrated Care

Background: Chronic renal failure is a chronic medical condition characterized by a progressive and irreversible loss of kidney function. Up to 50% of patients undergoing dialysis experience symptoms of depression and anxiety: what is the impact of individual factors and medical conditions on the mental health issue? The present study was carried out to investigate the individual factors (biomarkers and psychological dimensions) of end-stage renal disease patients dealing with dialysis, analyzing their predictor values for developing negative disease adaptations by an allostatic paradigm. Methods: We conducted an observational study on 35 patients affected by end-stage renal disease; biological and psychological markers have been detected. We conducted descriptive statistical analyses (t-tests) and performed a hierarchical regression analysis to investigate the relationship between pathological medical conditions and psychological dimensions. Results: The findings showed a positive correlation between creatinine levels and psychological distress as well as stress index. No significant effect of “time of dialysis”, “time from diagnosis”, “age” and “personality traits” was found. Conclusion: Our findings showed that personality traits did not represent a protective factor by moderating positive emotional adaptations; conversely, creatinine levels appeared predictive for negative emotional adaptations. High levels of creatinine were found to be positively associated with high stress levels as well psychological distress. According to the allostatic paradigm, end-stage renal disease patients could experience an allostatic load and more overload towards poor health outcomes; integrated biological and psychological measurements could prevent increased negative mental health through a patient-centered approach.

Psychosocial Assessment of Transplant Candidates: Inter-rater Reliability and Concurrent Validity of the Japanese Version of the Stanford Integrated Psychosocial Assessment for Transplantation

BACKGROUND

The Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) is a comprehensive instrument developed to provide a standardized, objective, and evidence-based psychosocial evaluation of the main pretransplant psychosocial risk factors that may influence transplant outcomes.

OBJECTIVE

Because established assessment procedures or standardized tools designed to perform pre-solid organ transplant psychosocial evaluation are currently unavailable in Japan, the present study aimed to develop and preliminarily validate the Japanese version of the SIPAT.

METHODS

First, the Japanese version of the SIPAT was developed using standard forward-back-translation procedures. Then, the Japanese versions of the SIPAT and the Japanese version of Psychosocial Assessment of Candidates for Transplant were retrospectively and blindly applied to 107 transplant cases by 4 independent raters.

RESULTS

The interrater reliability of the scores obtained with the Japanese version of the SIPAT was excellent (Pearson's correlation coefficient = 0.86). The concurrent validity of the SIPAT to the Psychosocial Assessment of Candidates for Transplant for each examiner was substantial (Spearman's rank correlation coefficient = -0.66).

CONCLUSION

These findings suggest that the Japanese version of the SIPAT is a promising and reliable instrument. Further research is required to test the predictive validity of the Japanese version of the SIPAT.

Psychosocial Evaluation of Candidates for Solid Organ Transplantation

Transplant candidates should undergo an assessment of their mental health, social support, lifestyle, and behaviors. The primary aims of this "psychosocial evaluation" are to ensure that transplantation is of benefit to life expectancy and quality of life, and to allow optimization of the candidate and transplant outcomes. The content of psychosocial evaluations is informed by evidence regarding pretransplant psychosocial predictors of transplant outcomes. This review summarizes the current literature on pretransplant psychosocial predictors of transplant outcomes across differing solid organ transplants and discusses the limitations of existing research. Pretransplant depression, substance misuse, and nonadherence are associated with poorer posttransplant outcomes. Depression, smoking, and high levels of prescription opioid use are associated with reduced posttransplant survival. Pretransplant nonadherence is associated with posttransplant rejection, and nonadherence may mediate the effects of other psychosocial variables such as substance misuse. There is evidence to suggest that social support is associated with likelihood of substance misuse relapse after transplantation, but there is a lack of consistent evidence for an association between social support and posttransplant adherence, rejection, or survival across all organ transplant types. Psychosocial evaluations should be undertaken by a trained individual and should comprise multiple consultations with the transplant candidate, family members, and healthcare professionals. Tools exist that can be useful for guiding and standardizing assessment, but research is needed to determine how well scores predict posttransplant outcomes. Few studies have evaluated interventions designed to improve psychosocial functioning specifically pretransplant. We highlight the challenges of carrying out such research and make recommendations regarding future work.

Psychosocial characteristics of patients evaluated for kidney transplant and associations with functional and frailty metrics at a veterans affairs hospital

BACKGROUND

The effect of psychosocial problems on listing outcomes and potential interactions with functional metrics is not well-characterized among Veteran transplant candidates.

METHODS

The results from psychosocial evaluations, frailty metrics, and biochemical markers were collected on 375 consecutive Veteran kidney transplant candidates. Psychosocial diagnoses were compared between patients listed or denied for transplant. Functional abilities were compared among patients with or without psychosocial diagnoses and then evaluated based on reason for denial.

RESULTS

Eighty-four percent of patients had a psychosocial diagnosis. Common issues included substance or alcohol abuse (62%), psychiatric diagnoses (50%), and poor adherence (25%). Patients with psychiatric diagnoses, cognitive impairments, and poor adherence were more likely to be denied for transplant (P < .05). Patients with depression, PTSD, and anxiety did not have worse functional ability, but experienced more exhaustion than patients without these problems. Patients denied for medical but not purely psychosocial reasons had worse troponin and functional metrics compared with listed patients.

CONCLUSION

Over 80% of patients with a psychosocial diagnosis were listed; however, poor adherence was a particularly important reason for denial for purely psychosocial reasons. Patients with psychosocial diagnoses generally were not more functionally limited than their counterparts without psychosocial diagnoses or those listed for transplant.

LIVER TRANSPLANTATION: TACROLIMUS BLOOD LEVELS VARIATION AND SURVIVAL, REJECTION AND DEATH OUTCOMES

BACKGROUND

Immunosuppressive drugs have important role in transplant of solid grafts, it aim avoid episodes of acute and chronic rejection and improving graft survival and patient survival. In Brazil, in 2016, liver transplantation was the third most frequent, with 1,880 transplants performed, of which 150 in Rio Grande do Sul. Several studies evaluated the association between variability in blood levels of immunosuppressive tacrolimus and late acute cellular graft rejection.

OBJECTIVE

To investigate the association of tacrolimus blood levels with clinical outcomes late acute cellular rejection, death, patient survival and graft survival in patients undergoing liver transplantation.

METHODS

This is a retrospective longitudinal study including patients submitted to adult liver transplantation by the Liver Transplantation Group in the Santa Casa de Misericórdia Hospital of Porto Alegre, from January 2006 to January 2013, and who used tacrolimus as immunosuppressive therapy.

RESULTS

Of the 127 patients included in the study, the majority were male (70.1%), 52-60 years old (33.9%) at the transplant. The most frequent causes of liver transplantation in this series were hepatitis C virus and hepatocellular carcinoma (24.4%) and alcohol (15.7%). Thirteen patients had late acute cellular rejection (10.2%); of these, three had two episodes. Regarding severity classification, seven patients had mild late acute cellular rejection. The mean time of rejection after liver transplantation was 14 months (ranging from 8 to 33 months). Overall survival was 8.98 years. Regarding tacrolimus blood levels, 52 patients with a variation ≥2 standard deviations were identified. Of these patients, eight had rejection; however, the association was not significant (P=0.146). A significant association was found between variation ≥2 standard deviations in tacrolimus blood levels and death (P=0.023) and survival (P=0.019). Regarding 5-year follow-up of graft survival, being two standard deviations above increases by 2.26 times the risk of transplanted graft loss, and for each unit of increase of standard deviation of tacrolimus blood levels there is a two-fold increase in the risk of graft loss in 5 years.

CONCLUSION

Increased risk of graft loss associated with increased standard deviations of tacrolimus blood levels may indicate the need for more rigorous and prospective monitoring of tacrolimus blood levels.

Dialysis Nonadherence and Kidney Transplant Outcomes: A Retrospective Cohort Study

RATIONALE AND OBJECTIVE

Concerns about non-adherent behaviors often prevent dialysis patients from entering waitlists for transplantation, despite an inconsistent association with posttransplant outcomes. We examined the association between plausible metrics of non-adherence related to dialysis treatment and posttransplant outcomes.

STUDY DESIGN

Retrospective cohort. We linked national dialysis treatment data with transplant registry data.

SETTING AND PARTICIPANTS

Adult patients on maintenance hemodialysis from 1/1/2004-12/31/2014 who received a kidney transplant at US centers.

EXPOSURES

We examined five nonadherence metrics: serum potassium (≥5.2 mEq/L), serum phosphorus (>5.5 mg/dL), intradialytic weight gain (IDWG, ≥5 L), shortened treatments (≥30 minutes) and missed treatments (≥1); missed treatment data was only available for 2004-2009. These metrics were characterized as the proportion of time under observation. Dialysis observation time was divided into 3-month intervals (quarters) and the number of "non-adherent" measurements in each domain was calculated for each quarter.

OUTCOMES

Allograft loss; mortality; and acute rejection in the first posttransplant year.

ANALYTICAL APPROACH

Using Cox proportional hazards and logistic regression, we estimated the hazard ratios (HRs) for graft loss and mortality, and odds ratios (OR) for rejection.

RESULTS

9543 patients met inclusion criteria. In our primary model, hyperphosphatemia (aHR 1.27, 05% CI 1.08-1.49), IDWG (aHR 1.39, 95% CI 1.23-1.59) and shortened treatments (aHR 1.54, 95% CI 1.12-2.13) were associated with greater rates of allograft loss but hyperkalemia was not. IDWG (aHR 1.49, 95% CI 1.29-1.73) and shortened treatments (aHR 1.34, 95% CI 1.13-1.58) were associated with mortality while hyperkalemia and hyperphosphatemia were not. Only shortened treatments was associated with an increased risk of acute rejection (aOR 3.88, 95% CI 1.98-7.58). In models limited to the years 2004 to 2009 that included missed treatments, missed treatments were only associated with mortality.

LIMITATIONS

Unmeasured confounding (e.g., dietary data); adherence metrics used may have multiple, complex causes.

CONCLUSIONS

Plausible measures of dialysis nonadherence have long-term associations with allograft and patient survival. Behavioral metrics were more closely associated with outcomes than laboratory markers. The implications of non-adherent behaviors for dialysis patients must be carefully considered before excluding patients from transplantation.

Telemedicine based remote monitoring after liver transplantation: Feasible in a select group and a more stringent control of immunosuppression

Telemedicine gained interest in liver transplant patients but focused until now on the early post‐operative period. This prospective cohort study assessed feasibility, safety, and clinical beneficial effects of a telemedicine based remote monitoring program (TRMP) for the chronic follow‐up of adult liver transplant recipients. Between November 2017 and August 2019, a total of 87 of the 115 selected patients (76%) started the TRMP. Over the 2 years study period, none of the patients switched to standard follow‐up: 39/87 (45%) continued to do this autonomously and 48/87 (55%) stopped to report their data personally but communicated their lab values to the nurse. The other 28/115 (11%) patients who did not accept the TRMP continued the standard follow‐up. There was no difference in educational level between the three groups. Remote monitoring did not result in an increase in liver graft rejection and need of hospitalization. TRMP was associated with a higher number of tacrolimus level determinations and tacrolimus blood level concentrations could be kept lower. In conclusion, our results show that in patients with a stable clinical condition there is a high willingness to participate in TRMP and that this approach is safe. Remote monitoring allowed a stringent follow‐up of tacrolimus levels.

Demoralization syndrome among cardiac transplant recipients

AIMS AND OBJECTIVES

To investigate the characteristics and prevalence of demoralisation syndrome among heart transplantation patients in Taiwan.

BACKGROUND

Patients with end-stage heart failure who have undergone cardiac transplantation are at risk of demoralisation syndrome. Demoralisation syndrome has been studied in cancer populations, but our understanding of the syndrome among heart transplant recipients is limited.

DESIGN AND METHODS

The study adopted a cross-sectional design and analysed the baseline data from a longitudinal study with cardiac transplant patients at a heart centre in northern Taiwan. A structured questionnaire, namely the Demoralization Scale-Mandarin Version (DS-MV), was used to assess demoralisation syndrome. Hierarchical regression was applied to determine the predictors of demoralisation. Reporting was consistent with the STROBE checklist.

RESULTS

There were a total of 84 participants with an average age of 51.9 years and a time since heart transplantation of around 4.1 years. Among them, the prevalence of demoralisation syndrome was 35.8%, and 57.1% coped well with stress. In addition, on the DS-MV, participants tended to choose sentences with positive rather than negative wording. Our data showed that cardiac transplant recipients with stress have higher possibility suffering from demoralisation syndrome; poor renal function and those who cannot relive from stress are predictors for loss of meaning.

CONCLUSIONS

Chinese individuals tend to hide their weaknesses; nevertheless, demoralisation syndrome among cardiac transplant recipients, as related to stress status and kidney function, is still remarkable.

RELEVANCE TO CLINICAL PRACTICE

Since demoralisation is preventable, further research on this phenomenon in the cardiac transplant population is warranted and needs to be developed.

2020 position statement and recommendations of the European Liver and Intestine Transplantation Association (ELITA): management of hepatitis B virus-related infection before and after liver transplantation

BACKGROUND

Prophylaxis of HBV recurrence is critical after liver transplantation in HBV patients. Despite new prophylactic schemes, most European LT centres persist on a conservative approach combining hepatitis B immunoglobulin (HBIG) and nucleos(t)ides analogues (NA).

AIM

This setting prompted the European Liver Intestine Transplantation Association (ELITA) to look for a consensus on the prevention of HBV recurrence.

METHODS

Based on a 4-round Delphi process, ELITA investigated 16 research questions and established 50 recommendations.

RESULTS

Prophylaxis should be driven according to 3 simplified risk groups: Low and high virological risk patients, with undetectable and detectable HBV DNA pre-LT, respectively, and special populations (HDV, HCC, poorly adherent patients). In low-risk patients, short-term (4 weeks) combination of third-generation NA+ HBIG, or third generation NA monotherapy can be considered as prophylactic options. In high-risk patients, HBIG can be discontinued once HBV DNA undetectable. Combined therapy for 1 year is advised. HBV-HCC patients should be treated according to their virological risk. In HDV/HBV patients, indefinite dual prophylaxis remains the gold standard. Full withdrawal of HBV prophylaxis following or not HBV vaccination should only be attempted in the setting of clinical trials. Organs from HBsAg+ve donors may be considered after assessment of risks, benefits, and patient consent. They should not be used if HDV is present. In poorly adherent patients, dual long-term prophylaxis is recommended. Budget impact analysis should be taken into account to drive prophylactic regimen.

CONCLUSIONS

These ELITA recommendations should stimulate a more rational and homogeneous approach to HBV prophylaxis across LT programs.

Uterine Transplantation: Review of Livebirths and Reproductive Implications

Uterine transplantation (UTx) is a fertility restoring treatment for women with absolute uterine factor infertility. At a time when there is no question of the procedure's feasibility, and as the number of livebirths begins to increase exponentially, various important reproductive, fetal, and maternal medicine implications have emerged. Detailed outcomes from 17 livebirths following UTx are now available, which are reviewed herein, along with contextualized extrapolation from pregnancy outcomes in other solid organ transplants. Differences in recipient demographics and reproductive aspirations between UTx and other transplant recipients make extrapolating management strategies and outcomes in other solid organ transplants inappropriate. Whereas preterm delivery remains prominent, small for gestational age or hypertensive disorders do not appear to be as prevalent following UTx when compared to other solid organ transplants. Given the primary objective of undertaking UTx is to achieve a livebirth, publication of reproductive outcomes is essential at this early stage, to reflect on and optimize the management of future cases.

The relation between psychological distress and medication adherence in lung transplant candidates and recipients: A cross-sectional study

AIMS AND OBJECTIVES

To explore the prevalence of psychological distress such as anxiety, depression and post-traumatic stress disorder and its associations with medication adherence in lung transplant patients.

BACKGROUND

Psychological distress after lung transplantation may impact clinical outcomes by associated behaviours such as non-adherence to medication. Evidence about the relation between psychological distress and medication adherence in lung transplant patients is limited and not well explained.

DESIGN AND METHODS

We conducted a single-centre study with a cross-sectional design in 73 lung transplant candidates and 116 recipients. Questionnaires were the Brief Symptom Inventory, Impact of Event Scale and Basel Assessment of Adherence to Immunosuppressive Medications Scale. The STROBE checklist was monitored.

RESULTS

In candidates, 39.7% reported (sub)clinical symptoms of depression, in recipients this was 21.6%. We observed suicidal ideation in recipients (8.6%), and candidates (5.5%). The prevalence of (sub)clinical symptoms of anxiety was 38.3% in candidates and 33.7% in recipients. After lung transplantation, 12% of the recipients reported clinical symptoms of PTSD related to the transplantation. Symptoms of anxiety and medication adherence were significantly and positively related in transplant recipients. We found no association between depressive or post-traumatic stress symptoms, and medication adherence.

CONCLUSIONS

In lung transplant patients, we found a high prevalence of symptoms of depression and anxiety. Recipients had high levels of post-traumatic stress symptoms related to the transplantation. The prevalence of suicidal ideation was unexpectedly high in recipients. After lung transplantation, higher levels of anxiety were related to better medication adherence. We propose that LTX recipients are very anxious to develop dyspnoea and therefore take their medication more conscientiously.

RELEVANCE TO CLINICAL PRACTICE

The clinical nurse specialist can play a key role in identifying and addressing psychological and behavioural problems. More prospective research on the role of anxiety and dyspnoea in lung transplant recipients is recommended.

Lung transplantation: candidate selection and timing of transplant

PURPOSE OF REVIEW

Over the past two decades, lung transplant has become the mainstay of treatment for several end-stage lung diseases. As the field continues to evolve, the criteria for referral and listing have also changed. The last update to these guidelines was in 2014 and several studies since then have changed how patients are transplanted. Our article aims to briefly discuss these updates in lung transplantation.

RECENT FINDINGS

This article discusses the importance of early referral of patients for lung transplantation and the concept of the 'transplant window'. We review the referral and listing criteria for some common pulmonary diseases and also cite the updated literature surrounding the absolute and relative contraindications keeping in mind that they are a constantly moving target. Frailty and psychosocial barriers are difficult to assess with the current assessment tools but continue to impact posttransplant outcomes. Finally, we discuss the limited data on transplantation in acute respiratory distress syndrome (ARDS) due to COVID19 as well as extracorporeal membrane oxygenation bridge to transplantation.

SUMMARY

The findings discussed in this article will strongly impact, if not already, how we select candidates for lung transplantation. It also addresses some aspects of lung transplant such as frailty and ARDS, which need better assessment tools and clinical data.

KDOQI US Commentary on the 2020 KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation

Evaluation of patients for kidney transplant candidacy is a comprehensive process that involves a detailed assessment of medical and surgical issues, psychosocial factors, and patients' physical and cognitive abilities with an aim of balancing the benefits of transplantation and potential risks of surgery and long-term immunosuppression. There is considerable variability among transplant centers in their approach to evaluation and decision-making regarding transplant candidacy. The 2020 KDIGO (Kidney Disease: Improving Guidelines Outcome) clinical practice guideline on the evaluation and management of candidates for kidney transplantation provides practice recommendations that can serve as a useful reference guide to transplant professionals. The guideline, covering a broad range of topics, was developed by an international group of experts from transplant and nephrology through a review of literature published until May 2019. A work group of US transplant nephrologists convened by NKF-KDOQI (National Kidney Foundation-Kidney Disease Quality Initiative) chose key topics for this commentary with a goal of presenting a broad discussion to the US transplant community. Each section of this article has a summary of the key KDIGO guideline recommendations, followed by a brief commentary on the recommendations, their clinical utility, and potential implementation challenges. The KDOQI work group agrees broadly with the KDIGO recommendations but also recognizes and highlights the decision-making challenges that arise from lack of high-quality evidence and the need to balance equity with utility of organ transplantation.

The Psychosocial Assessment of Transplant Candidates: Internal Consistency, Interrater Reliability, and Content Validity of the Thai Version of the Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT-Thai Version)

BACKGROUND

Standardized pretransplant psychosocial assessment is critically needed in Thailand to optimize medical and psychosocial outcomes after transplantation. The Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) is a comprehensive and evidence-based tool that has demonstrated excellent reliability and predictive value in many psychosocial transplant studies. We translated the SIPAT into Thai and explored the validity and reliability of the SIPAT-Thai version among Thai transplant recipients.

METHODS

We translated the original SIPAT into Thai following the World Health Organization's standard forward-backward translation procedure and then cross-sectionally assessed its validity and reliability in 110 Thai solid organ transplant candidates. The correlation between background data, total, and sectional scoring results of SIPAT-Thai were also analyzed.

RESULTS

The SIPAT-Thai demonstrated moderate to good reliability, which was represented by internal consistency with a Cronbach α of .751 and interrater reliability with a κ value at 0.767. The index of item-objective congruence value was 0.94, indicating good the content validity.

CONCLUSIONS

The SIPAT-Thai was systematically translated and shown to have acceptable validity and a moderate to good reliability index. The use of the SIPAT-Thai would provide a standardized, evidence-based, and a more systematic pretransplant psychosocial evaluation process for transplant candidates in Thailand.

The Preimplantation Psychosocial Evaluation and Prediction of Clinical Outcomes During Mechanical Circulatory Support: What Information Is Most Prognostic?

BACKGROUND

Psychosocial evaluations are required for long-term mechanical circulatory support (MCS) candidates, no matter whether MCS will be destination therapy (DT) or a bridge to heart transplantation. Although guidelines specify psychosocial contraindications to MCS, there is no comprehensive examination of which psychosocial evaluation domains are most prognostic for clinical outcomes. We evaluated whether overall psychosocial risk, determined across all psychosocial domains, predicted outcomes, and which specific domains appeared responsible for any effects.

METHODS

A single-site retrospective analysis was performed for adults receiving MCS between April 2004 and December 2017. Using an established rating system, we coded psychosocial evaluations to identify patients at low, moderate, or high overall risk. We similarly determined risk within each of 10 individual psychosocial domains. Multivariable analyses evaluated whether psychosocial risk predicted clinical decisions about MCS use (DT versus bridge), and postimplantation mortality, transplantation, rehospitalization, MCS pump exchange, and standardly defined adverse medical events (AEs).

RESULTS

In 241 MCS recipients, greater overall psychosocial risk increased the likelihood of a DT decision (odds ratio, 1.76; P = 0.017); and postimplantation pump exchange and occurrence of AEs (hazard ratios [HRs] ≥ 1.25; P ≤ 0.042). The individual AEs most strongly predicted were cardiac arrhythmias and device malfunctions (HRs ≥ 1.39; P ≤ 0.032). The specific psychosocial domains predicting at least 1 study outcome were mental health problem severity, poorer medical adherence, and substance use (odds ratios and HRs ≥ 1.32; P ≤ 0.010).

CONCLUSIONS

The psychosocial evaluation predicts not only clinical decisions about MCS use (DT versus bridge) but important postimplantation outcomes. Strategies to address psychosocial risk factors before or soon after implantation may help to reduce postimplantation clinical risks.

KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation

The 2020 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation is intended to assist health care professionals worldwide who evaluate and manage potential candidates for deceased or living donor kidney transplantation. This guideline addresses general candidacy issues such as access to transplantation, patient demographic and health status factors, and immunological and psychosocial assessment. The roles of various risk factors and comorbid conditions governing an individual's suitability for transplantation such as adherence, tobacco use, diabetes, obesity, perioperative issues, causes of kidney failure, infections, malignancy, pulmonary disease, cardiac and peripheral arterial disease, neurologic disease, gastrointestinal and liver disease, hematologic disease, and bone and mineral disorder are also addressed. This guideline provides recommendations for evaluation of individual aspects of a candidate's profile such that each risk factor and comorbidity are considered separately. The goal is to assist the clinical team to assimilate all data relevant to an individual, consider this within their local health context, and make an overall judgment on candidacy for transplantation. The guideline development process followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach. Guideline recommendations are primarily based on systematic reviews of relevant studies and our assessment of the quality of that evidence, and the strengths of recommendations are provided. Limitations of the evidence are discussed with differences from previous guidelines noted and suggestions for future research are also provided.

Advances in Rejection Management: Prevention and Treatment

Extended survival of liver transplant recipients has brought rejection management to the forefront of liver transplant research. This article discusses T-cell-mediated rejection, antibody-mediated rejection, and chronic rejection. We focus on the prevention and then discuss treatment options. Future directions of rejection management include biomarkers of rejection, which may allow for monitoring of patients who are considered high risk for rejection and detection of rejection before there is any clinical evidence to improve graft and patient survival. With improved graft life and survival of liver transplant recipients, the new frontier of rejection management focuses on immunosuppression minimization, withdrawal, and personalization.

Medication non-adherence among liver transplant recipients

PURPOSE OF REVIEW

We provide an overview of the recent evidence on the prevalence, risk factors, and consequences of medication non-adherence (NA) in liver transplant (LT) recipients.

RECENT FINDINGS

NA in LT is associated with socio-demographic and medication-related factors, low social support, and poor health literacy. Patient-reported adherence is one of the most common methods to measure NA using validated assessments; immunosuppression (IS) drug levels and electronic monitoring may also be used. Simplification of IS regimens such as the conversion from twice daily to once daily has been shown to be safe, effective, and improves adherence. Relatively few studies have prospectively investigated NA predictors or interventions to reduce NA in LT.

SUMMARY

Medication non-adherence is a multi-faceted issue that is common among LT recipients and associated with adverse outcomes. NA in LT recipients warrants further study as only a few interventions have been published focused on reducing NA in LT.

Depression, Immunosuppressant Levels, and Clinical Outcomes in Postlung Transplant Recipients

OBJECTIVE

Posttransplant depression has been linked to increased risk for adverse outcomes in lung transplant patients. Maintaining target serum immunosuppressant levels is also essential for optimal lung transplant clinical outcome and may be a crucial predictor of outcomes. Because depression could affect medication nonadherence, resulting in out-of-range immunosuppressant levels, we examined the relationship between posttransplant depression, immunosuppressant medication trough level variability, indexed by out-of-range values on clinical outcomes and coefficient of variability, and clinical outcomes.

METHOD

A consecutive series of 236 lung transplant recipients completed the Center for Epidemiological Studies-Depression two-month posttransplant. Immunosuppressant trough levels (i.e., tacrolimus or cyclosporine) within the range of individualized immunosuppressant targets were obtained at three-, six-, nine-month follow-up clinic visits. Clinical outcomes including hospitalizations and mortality were obtained from medical records.

RESULTS

Fourteen percent of patients were classified as depressed (Center for Epidemiological Studies-Depression ≥16), 144 (61%) of patients had at least 25% out-of-range immunosuppressant values, and the average coefficient of variability was 36%. Over a median of 2.6 years (interquartile range = 1.2), 32 participants died (14%) and 144 (61%) had at least one unplanned, transplant-related hospitalization. Both depression (hazard ratio = 1.45 (1.19, 1.76), p < . 01) and immunosuppressant variation (immunosuppressant out-of-range: hazard ratio = 1.41 (1.10, 1.81), p < .01) independently predicted more frequent hospitalizations and higher mortality.

CONCLUSIONS

Early posttransplant depression was associated with significantly worse clinical outcomes. While immunosuppressant level variability is also related to adverse outcomes, such variability does not account for increased risk observed with depression.

Care of the Renal Transplant Patient

Renal transplant has become a mainstay of treatment of patients with chronic renal failure. With improving survival outcomes, primary care physicians should be informed of the nuances that come with the ongoing care of this population and feel empowered to take part in the multidisciplinary care of these patients. This article provides an overview of the renal transplant process from initial evaluation through surgery and then focuses on long-term issues that renal transplant patients face in the primary care setting.

From Nonadherence to Adherence

Medication nonadherence (MNA) after solid organ transplantation is highly prevalent and associated with (late) (sub)clinical acute rejection, graft dysfunction and graft loss, development of donor-specific anti-HLA antibodies, and antibody-mediated rejection. MNA is predominantly unintentional and originates from barriers to adherence that are often multifactorial and complex. Tools to establish an early diagnosis of MNA include incorporation of MNA as a vital sign in daily clinical practice, self-reporting using validated questionnaires, calculating intrapatient variability in drug exposure and applying electronic monitoring, and recent audio and video technologies such as in home telemonitoring. MNA is a modifiable risk factor after organ transplantation, and treatment is most effective if a multimodal approach is used. Management of MNA comprises education (cognitive) and counseling (behavioral) that require the involvement of a trained multidisciplinary team [ideally physician, nurse (specialist), social worker, transplant coordinator, psychologist, clinical pharmacist], electronic reminder and support systems (eg, Medication Event Monitoring System, smartphone), and different types of novel mobile health applications as well as simplification of the medication dosing regimen. Future studies that evaluate novel therapeutic approaches for MNA should assure the use of reliable MNA measures, focus on multimodal individualized therapy for enriched nonadherent target populations (eg, adolescents), and incorporate clinically relevant endpoints. Costs, time, and personnel investments should be taken into account when assessing scalability and cost-effectiveness of novel therapeutic strategies. This review provides suggestions how different types of transplant centers can set up a dedicated MNA program according to available resources to define and achieve realistic clinical goals in managing MNA.

Prospective single-centre clinical observational study on electronically monitored medication non-adherence, its psychosocial risk factors and lifestyle behaviours after heart transplantation: a study protocol

INTRODUCTION

In heart transplant recipients (HTRs), non-adherence (NA) to immunosuppressive (IS) medication and to recommended lifestyle behaviours are a common phenomenon and associated with higher risk of allograft rejection, organ loss and mortality. Risk factors for NA are highly diverse and still insufficiently researched. Precise measures of NA and an accurate understanding of its aetiology are of undisputable importance to detect patients at risk and intervene accordingly. The aim of this study is to assess the accuracy and concordance of different measures for NA as well as to determine potential risk factors.

METHODS AND ANALYSIS

This is a single-centre prospective observational trial. HTRs who are at least aged 18 are no less than 6 months post-transplant and receive tacrolimus (Prograf or Advagraf), cyclosporine (Sandimmun) or everolimus (Certican) as their prescribed IS medication are eligible for participation. We only include patients during the phase of medication implementation. At study enrolment, we assess depression, health-related quality of life, self-efficacy, social support, attachment, experiences and attitudes towards IS medication, emotional responses after transplantation, satisfaction with information about IS medication and perceptions and beliefs about medications. We further ask patients to rate their lifestyle behaviours concerning alcohol, smoking, diet, physical activity, sun protection and appointment keeping via questionnaires. Three different measurement methods for NA are applied at T0: self-reports, physician's estimates and IS trough levels. NA is monitored prospectively using an electronic multicompartment pillbox (MEMS, VAICA) over a 3-month period. Meanwhile, participants receive phone calls every second week to obtain additional self-reports, resulting in a total of seven measurement points.

ETHICS AND DISSEMINATION

The study was approved by the Clinical Ethics Committee of the University Hospital Erlangen (Friedrich-Alexander-University, Erlangen-Nürnberg). Written informed consent is attained from all participants. The results of this study will be published in peer-reviewed journals and presented at conferences.

TRIAL REGISTRATION NUMBER

DRKS00020496.

The structural conundrum of parolees and kidney transplantation

In the United States, there are a large number of incarcerated individuals, resulting in high numbers of previously incarcerated individuals out on parole undergoing reentry into society. An aging prison population translates to an older parolee population and increased incidence of kidney disease requiring either long-term dialysis or transplantation. This paper argues that due to challenges specific to the parolee population as well as societal biases and priorities, Transplant Centers and healthcare professionals face an ethical imperative to attend to the needs of parolees as a class and take steps to address challenges related to access to Centers for renal transplantation evaluation for this disadvantaged group. It will first review the regulatory context of kidney transplantation and highlight the specific ways it effects parolees. The paper will then discuss the broader social context of parolee reentry into society and barriers faced by parolees in this process. This ethical analysis examines the complexity of these issues, and deliberates on ways to balance the competing priorities of justice, respect for this patient population as individuals and as a disadvantaged class, and the societal interests regarding organ allocation and considerable economic burdens of end-stage renal disease on parolees, the justice system, and the public.