Prevalence and determinants of physical activity and fluid intake in kidney transplant recipients

Water/fluid intake in Kıdney transplant recipients: An underrated topic

Although kidney transplantation (KT) is the best treatment option for end-stage kidney disease, long-term complications such as chronic kidney allograft dysfunction and cardiovascular disorders are observed. To decrease these complications, preventive measures must be applied in kidney transplant recipients (KTRs). One of these common measures is the increase of water/fluid intake although this is not evidence-based practice. Indeed, surprisingly very limited studies evaluated the impact of increased water/fluid intake on graft function, with small number of KTRs and short term follow-up. We suggest that the water/fluid intake should be personalized based on baseline graft function, time onset after KT (which water homeostasis changes), presence of hyponatremia and hypervolemia, concomitant medications, and patient willingness. Methods for estimating water/fluid intake (direct measurement, 24-h urine volume measurement, urine osmolarity) has both advantages and drawbacks and the best method has not been identified. Increase of water/fluid intake in specific conditions (in hot, and humid weather, before exercise, during Ramadan fasting) or in distinct KTRs (KTRs with de novo nephrolithiasis, frequent urinary tract infections) is not tested. Furthermore, the relationship between water/fluid intake and major cardiovascular adverse events are not known. There is no doubt that minimum amount of water/fluid intake is necessary for graft function (the amount is not known) but there is no evidence for a particular target level of water/fluid intake. In the current review, we summarize the studies assessing fluid/water intake in KTR, explained the pathophysiologic basis of water disorders in early period of KT and late after KT, elucidate conflicts and unknown issues of water intake in KTRs and suggest future research needs.

Effect of Physical Function on Access to Repeat Kidney Transplantation

Background: The long-term success rate of kidney transplantation is disappointing, with repeat transplantation necessary for more than half of recipients. When a repeat kidney transplantation is needed, patients are often elderly and suffer from underlying advanced kidney disease, comorbidities, and adverse effects of immunosuppressants, leading to physical function limitations. Limited physical function is known to hinder access to an initial kidney transplantation, but there is no information about its impact on repeat transplantations. Objective: This study aimed to determine the effect of physical function on access to wait-listing for repeat transplantation. Methods: Data from the national registry was utilized to analyze 28,884 kidney transplant recipients. Physical function was assessed with Karnofsky scores, and patients were categorized into three strata: total assistance, some assistance, and no assistance. Logistic regression and multivariate Cox proportional hazard models were used to assess the impact of physical function on waiting list access and duration until wait-listing, respectively. Results: Patients with greater physical independence were more likely to be wait-listed for repeat kidney transplantation. Highly sensitized patients, those with diabetes, Black patients, and elderly individuals had a lower likelihood of access to wait-listing after kidney failure. Interestingly, those with limited physical function, provided they remained in the work-up process, experienced a relatively shorter duration to wait-listing after graft failure.Conclusions: These findings highlight the need to promote and support physical function throughout the kidney transplant journey to improve access to repeat transplantation and subsequent patient outcomes.

Physical Inactivity: A Modifiable Risk Factor for Morbidity and Mortality in Kidney Transplantation

In patients with chronic kidney disease, sedentary behavior is widely recognized as a significant risk factor for cardiovascular disease, diabetes, obesity, osteoporosis, cancer, and depression. Nevertheless, the real impact of physical inactivity on the health of kidney transplant (KT) recipients remains uncertain. Over the last decade, there has been a renewed interest in exploring the effects of regular physical exercise on transplant-related outcomes. There is now mounting evidence that physical activity may reduce the burden of cardiovascular risk factors, preserve allograft function, minimize immunosuppression requirement, and ameliorate the quality of life of KT recipients. Many positive feedbacks can be detected in the early stages of the interventions and with a minimal exercise load. Despite these encouraging results, the perceived role of physical activity in the management of KT candidates and recipients is often underrated. The majority of trials on exercise training are small, relatively short, and focused on surrogate outcomes. While waiting for larger studies with longer follow-up, these statistical limitations should not discourage patients and doctors from initiating exercise and progressively increasing intensity and duration. This narrative review summarizes current knowledge about the deleterious effects of physical inactivity after KT. The benefits of regular physical exercise are also outlined.

Prevalence and correlates of physical activity across kidney disease stages: an observational multicentre study

BACKGROUND

People with chronic kidney disease (CKD) report high levels of physical inactivity, a major modifiable risk factor for morbidity and mortality. Understanding the biological, psychosocial and demographic causes of physical activity behaviour is essential for the development and improvement of potential health interventions and promotional initiatives. This study investigated the prevalence of physical inactivity and determined individual correlates of this behaviour in a large sample of patients across the spectrum of kidney disease.

METHODS

A total of 5656 people across all stages of CKD (1-2, 3, 4-5, haemodialysis, peritoneal dialysis and renal transplant recipients) were recruited from 17 sites in England from July 2012 to October 2018. Physical activity was evaluated using the General Practice Physical Activity Questionnaire. Self-reported cardiorespiratory fitness, self-efficacy and stage of change were also assessed. Binominal generalized linear mutually adjusted models were conducted to explore the associations between physical activity and correlate variables. This cross-sectional observational multi-centre study was registered retrospectively as ISRCTN87066351 (October 2015).

RESULTS

The prevalence of physical activity (6-34%) was low and worsened with disease progression. Being older, female and having a greater number of comorbidities were associated with greater odds of being physically inactive. Higher haemoglobin, cardiorespiratory fitness and self-efficacy levels were associated with increased odds of being active. Neither ethnicity nor smoking history had any effect on physical activity.

CONCLUSIONS

Levels of physical inactivity are high across all stages of CKD. The identification of stage-specific correlates of physical activity may help to prioritize factors in target groups of kidney patients and improve the development and improvement of public health interventions.

Physical activity and its correlates in a pediatric solid-organ transplant population

PA has been shown to have benefits in SOT patients. Studies assessing physical activity levels and its correlates in a pediatric solid-organ transplant population are limited. The aim of this study was to assess PA levels and identify baseline and contemporaneous factors that contribute to PA in a pediatric SOT population. A retrospective cross-sectional review was performed on 58 pediatric transplant patients (16 heart, 29 kidney, and 13 liver transplant). PA was measured by PAQ-C or PAQ-A. Demographics, baseline, and contemporaneous factors were collected. There were no significant differences in baseline and contemporaneous characteristics between heart, kidney, and liver transplant recipients. SOT recipients were 15.2 [12.3-17.3] years old at time of completing the PAQ. Median PAQ score was 2.2 [1.7-2.9]. There were no significant differences in PAQ scores between organ transplant type or between genders. Lower PAQ score was associated with sensory disability (9 vs 49 without disability; P = <.01) and age at time of completing the PAQ (r = -.50, P = <.01). These results suggest that older age at time of completing the PAQ and presence of sensory disability may influence PA levels in the pediatric SOT population.

Physical Activity and the Development of Post-Transplant Diabetes Mellitus, and Cardiovascular- and All-Cause Mortality in Renal Transplant Recipients

(1) Background: Little is currently known about the health impacts of daily-life moderate-to-vigorous physical activity (MVPA) in relation to the development of post-transplant diabetes mellitus (PTDM) and the long-term survival of renal transplant recipients (RTRs). (2) Methods: We analyzed self-reported data on MVPA within non-occupational and occupational domains, estimated with the SQUASH questionnaire, from a prospective cohort study of RTRs (n = 650) with a functioning graft exceeding 1 year. PTDM diagnoses were based on plasma glucose levels (≥126 mg/dL), HbA1c (≥6.5%), and the use of antidiabetic medication. Mortality data were retrieved from patient files up to the end of September 2015. (3) Results: During a median follow-up period of 5.3 years, 50 patients (10%) developed PTDM and 129 (19.8%) died. Of these deaths, 53 (8.9%) were caused by cardiovascular disease. Cox regression analyses showed that higher MVPA levels among patients were associated with a lower risk of PTDM (hazard ratio (HR); 95% confidence interval (95%CI) = 0.49; 0.25–0.96, p = 0.04), cardiovascular- (0.34; 0.15–0.77, p = 0.01), and all-cause mortality (0.37; 0.24–0.58, p < 0.001) compared with No-MVPA patients, independently of age, sex, and kidney function parameters. Associations of MVPA with cardiovascular and all-cause mortality remained significant and materially unchanged following further adjustments made for transplant characteristics, lifestyle factors, metabolic parameters, medication use, and creatinine excretion (muscle mass). However, the association between MVPA and PTDM was no longer significant after we adjusted for metabolic confounders and glucose levels. (4) Conclusion: Higher MVPA levels are associated with long-term health outcomes in RTRs.

Psychological and Psychopathological Aspects of Kidney Transplantation: A Systematic Review

Kidney transplantation is a serious event that involves profound psychological, relational and social changes both for the patient and his family context. Assessment of personality profile, awareness of disease, family and social support of the patient candidate for kidney transplantation are necessary because factors not adequately considered, can influence the success of the transplant and alter the psychological stability of the patient. The present study aims to provide a systematic review of the literature of the last twelve years (2006-2018), focusing in particular on patient's readiness level and illness management and on possible psychopathology. Sixty-two studies were examined. Based on the Downs and Black checklist, most studies (n = 32) were of high quality; 15 of which related to lifestyle, health education, and therapeutic adherence in post-renal transplantation, 17 studies concerned the possible existence of psychopathology and cognitive impairment of renal deceased transplanted subjects. The literature used has shown that the population of kidney transplant patients is exposed to a high risk of psychiatric disorders with repercussions on the quality of life and the risk of rejection. Therefore, an adequate pre-transplant psychosocial assessment is necessary, which allows a more in-depth knowledge of the candidate to plan coping strategies and possible post-transplant psychotherapy.

Physical Activity, Sedentary Time, and Associated Factors in Recipients of Solid-Organ Transplantation

BACKGROUND

Short-term survival after solid-organ transplantation has substantially improved, and the focus has shifted to long-term survival, including the role of physical activity (PA). Knowledge about PA and sedentary time in recipients of solid-organ transplantation is limited, and identification of the levels and associated factors is necessary for intervention development.

OBJECTIVE

The objectives of this study were to investigate the level of PA and sedentary time in recipients of solid-organ transplantation and to identify factors associated with these behaviors.

DESIGN

The design consisted of a cross-sectional survey.

METHODS

Questionnaires on PA level, sedentary time, and potential associated factors were used for recipients of solid-organ transplantation (kidney, liver, lung, and heart [N = 656]). Multiple regression analyses with a variable selection procedure were used.

RESULTS

Fewer than 60% of the recipients fulfilled the PA guideline. Factors significantly associated with a lower level of PA included being a woman, younger age (nonlinear), not actively working or being retired, physical limitations, and low expectations and self-confidence. Factors significantly associated with less sedentary time included exercise self-efficacy and not actively working or being retired. Significantly associated with more sedentary time were a high education level, fear of negative effects, physical limitations, and the motivator "health and physical outcomes." The type of transplantation did not significantly influence either of the outcome measures.

LIMITATIONS

The design did not allow for causal inferences to be made. The studied associated factors were limited to individual and interpersonal factors. Self-reported measures of PA and sedentary time were used.

CONCLUSIONS

In intervention development directed at increasing the level of PA and reducing sedentary time in recipients of solid-organ transplantation, attention should be paid to physical limitations, fear of negative effects, low expectations and self-confidence, health and physical outcomes, and exercise self-efficacy.

Prevalence and correlates of non-adherence to immunosuppressants and to health behaviours in patients after kidney transplantation in Brazil - the ADHERE BRAZIL multicentre study: a cross-sectional study protocol

BACKGROUND

Non-adherence to immunosuppressive therapy is a prevalent risk factor for poor clinical and after kidney transplantation (KT), and has contributed to the lack of improvement in long-term graft survival over the past decade. Understanding the multilevel correlates and risk factors of non-adherence is crucial to determine the optimal level for planning interventions, namely at the patient, health care provider, KT centre, and health care system level. Brazil, having the largest public transplantation program in the world and with regional differences regarding access to health services and service implementation, is in a unique position to study this multilevel approach. Therefore, the Adhere Brazil Study (ADHERE BRAZIL) was designed to assess the prevalence and variability of non-adherence to immunosuppressants and to health behaviours among adult KT recipients in Brazil, and to assess the multilevel correlates of non-adherence to immunosuppressive medication. We describe the rationale, design, and methodology of the ADHERE BRAZIL study.

METHODS/DESIGN

This is an observational, cross-sectional, multicentre study that includes 20 Brazilian KT centres. A stratified sampling approach is used, based on strata, with the following characteristics considered: geographical region and transplant activity (number of KTs per year). A random sample of patients (proportional to the size of the centre within each stratum) is selected from each centre. The prevalence of different health behaviours is assessed through self-report. The assessment of multilevel correlates of non-adherence is guided by the ecological model that considers factors at the level of the patient, health-care professional, and transplant centre, using established instruments or instruments developed for this study. Data will be collected over an 18-month period, with information obtained during the regular follow-up visits to the transplant outpatient clinic and directly entered into the Research Electronic Data Capture (RedCap) system. Data entry is performed by a trained professional who is part of the transplant team. The data collection began in December 2015.

DISCUSSION

This multicentre study is the first to evaluate multilevel correlates of non-adherence in KT patients and will provide a reliable estimate of non-adherence in Brazilian KT patients.

TRIAL REGISTRATION

ClinicalTrials.gov on 10/10/2013, NCT02066935 .

An integrative review of the methodology and findings regarding dietary adherence in end stage kidney disease

BACKGROUND

Dietary modification is an important component of the management of end stage kidney disease (ESKD). The diet for ESKD involves modifying energy and protein intake, and altering sodium, phosphate, potassium and fluid intake. There have been no comprehensive reviews to date on this topic. The aims of this integrative review were to (i) describe the methods used to measure dietary adherence (ii) determine the rate of dietary adherence and (iii) describe factors associated with dietary adherence in ESKD.

METHODS

The Web of Science and Scopus databases were searched using the search terms 'adherence' and 'end stage kidney disease'. Of the 787 potentially eligible papers retrieved, 60 papers of 24,743 patients were included in this review. Of these papers, 44 reported the rate of dietary adherence and 44 papers described factors associated with adherence.

RESULTS

Most of the evidence regarding dietary adherence is derived from studies of hemodialysis patients (72% of patients). The most common method of measuring dietary adherence in ESKD was subjective techniques (e.g. food diaries or adherence questionnaires). This was followed by indirect methods (e.g. serum potassium, phosphate or interdialytic weight gain). The weighted mean adherence rate to ESKD dietary recommendations was 31.5% and 68.5% for fluid recommendations. Adherence to protein, sodium, phosphate, and potassium recommendations were highly variable due to differences in measurement methods used, and were often derived from a limited evidence base. Socioeconomic status, age, social support and self-efficacy were associated with dietary adherence. However, factors such as taste, the impact of the diet on social eating occasions; and dietetic staffing also appear to play a role in dietary adherence.

CONCLUSION

Dietary adherence rates in people with ESKD are suboptimal. Further research is required on dietary adherence in patients with ESKD from different social, educational, economic and ethnic groups. This research may identify other factors which may impact upon adherence, and could be used to inform the design of future strategies to improve dietary adherence. Future research that reports not just the rate of adherence to individual components of the nutrient prescription but also the overall quality of the diet would be useful.

Health-related behaviours after 1 year of renal transplantation

Health-related behaviours and psychological distress were examined after kidney transplantation. Patients were evaluated at 1 month, 6 months and 1 year after transplantation. Participants completed the Healthy Behaviours Questionnaire and the Hospital Anxiety and Depression Scale. No significant differences in Healthy Behaviours Questionnaire’s total score and psychological comorbidity were observed at three time points. However, there was an increase in drug-consumer habits ( p < 0.05) and a reduction in sedentary lifestyle ( p < 0.05) at 6 months and 1 year. Moreover, at 1 year, post-transplant had increased the harmful health habits ( p < 0.05). In regression analysis, anxiety symptoms were significant predictors of Healthy Behaviours Questionnaire change at a year post-transplantation.

Effect of diagnosis with a chronic disease on physical activity behavior in middle-aged women

OBJECTIVE

Although regular physical activity is an effective secondary prevention strategy for patients with a chronic disease, it is unclear whether patients change their daily physical activity after being diagnosed. Therefore, the aims of this study were to (1) describe changes in levels of physical activity in middle-aged women before and after diagnosis with a chronic disease (heart disease, diabetes, asthma, breast cancer, arthritis, depression); and to (2) examine whether diagnosis with a chronic disease affects levels of physical activity in these women.

METHODS

Data from 5 surveys (1998-2010) of the Australian Longitudinal Study on Women's Health (ALSWH) were used. Participants (N=4840, born 1946-1951) completed surveys every three years, with questions about diseases and leisure time physical activity. The main outcome measure was physical activity, categorized as: nil/sedentary, low active, moderately active, highly active.

RESULTS

At each survey approximately half the middle-aged women did not meet the recommended level of physical activity. Between consecutive surveys, 41%-46% of the women did not change, 24%-30% decreased, and 24%-31% increased their physical activity level. These proportions of change were similar directly after diagnosis with a chronic disease, and in the years before or after diagnosis. Generalized estimating equations showed that there was no statistically significant effect of diagnosis with a chronic disease on levels of physical activity in women.

CONCLUSION

Despite the importance of physical activity for the management of chronic diseases, most women did not increase their physical activity after diagnosis. This illustrates a need for tailored interventions to enhance physical activity in newly diagnosed patients.

Adherence to a pedometer-based physical activity intervention following kidney transplant and impact on metabolic parameters

The majority of kidney transplant recipients die from cardiovascular events. Physical activity may be a modifiable risk factor for cardiovascular disease following transplant. The goal of our study was to examine adherence to a physical activity intervention following kidney transplant and its impact on metabolic parameters. All patients who received a kidney transplant at our center between 12/2010 and 12/2011 received usual care (n = 162), while patients transplanted between 12/2011 and 1/2013 received a 90-day pedometer-based physical activity intervention (n = 145). Metabolic parameters were assessed at four and 12 months post-transplant. Baseline demographics and clinical management were similar between cohorts. Adherence to the prescription was 36.5%. Patients in the physical activity cohort had lower systolic and diastolic blood pressure four months post-transplant compared to the usual care cohort (122 ± 18 vs. 126 ± 16 mmHg, p = 0.049 and 73 ± 10 vs. 77 ± 9, p = 0.004) and less impaired fasting glucose (20.7% vs. 30.9%, p = 0.04). Twelve-month outcomes were not different between cohorts. Over one-third of our cohort adhered to a pedometer-based physical activity intervention following kidney transplant, and the intervention was associated with improved metabolic parameters. Further study of post-transplant exercise interventions and methods to optimize long-term adherence are needed.

Considerations for a Primary Care Physician Assistant in Treating Kidney Transplant Recipients

The escalating amount of kidney transplant recipients (KTRs) represents a significant dilemma for primary care providers. As the number of physician assistants (PAs) has been steadily increasing in primary care in the United States, the utilization of these healthcare professionals presents a solution for the care of post-kidney transplant recipients. A physician assistant (PA) is a state licensed healthcare professional who practices medicine under physician supervision and can alleviate some of the increasing demands for primary patient care. Here we provide an outline of the crucial components and considerations for PAs caring for kidney transplant recipients. These include renal function and routine screenings, drug monitoring (both immunosuppressive and therapeutic), pre-existing and co-existing conditions, immunizations, nutrition, physical activity, infection, cancer, and the patient's emotional well-being. PAs should routinely monitor renal function and blood chemistry of KTRs. Drug monitoring of KTRs is a crucial responsibility of the PA because of the possible side-effects and potential drug-drug interactions. Therefore, PAs should obtain a careful and detailed patient history from KTRs. PAs should be aware of pre- and co-existing conditions of KTRs as this impacts treatment decisions. Regarding immunization, PAs should avoid administering vaccines containing live or attenuated viruses to KTRs. Because obesity following kidney transplantation is associated with decreased allograft survival, PAs should encourage KTRs to maintain a balanced diet with limited sugar. In addition, KTRs should be urged to gradually increase their levels of physical activity over subsequent years following surgery. PAs should be aware that immunosuppressive medications diminish immune defenses and make KTRs more susceptible to bacterial, viral, and fungal infections. Moreover, KTRs should be screened routinely for cancer due to the higher risk of development from immunosuppressive therapy. PAs must remain cognizant of the emotional well-being of the KTR, as many transplant patients struggle with fear, frustration, and acceptance.

Efficacy of a sun protection workbook for kidney transplant recipients: a randomized controlled trial of a culturally sensitive educational intervention

A culturally sensitive educational intervention that encouraged sun protection behaviors among kidney transplant recipients (KTRs) was developed and the short-term efficacy was evaluated. Non-Hispanic White, Hispanic/Latino and non-Hispanic Black patients, who received a transplant 2-24 months prior to the study, were randomized into two study groups: intervention versus standard of care. Electronic reminders tailored to the weather conditions were sent every 2 weeks by text message or email. Self-reported surveys and biologic measurements were obtained prior to the intervention and 6 weeks later. Among the 101 study participants, there was a statistically significant increase in knowledge, recognition of personal risk of developing skin cancer, willingness to change sun protection behavior and self-reported performance of sun protection in participants receiving the intervention in comparison with those receiving standard of care (p < 0.05). The pigment darkening of the sun-exposed forearm and sun damage of the forearm and sunburns/skin irritation from the sun were significantly less in participants receiving the intervention (p < 0.05). Providing sun protection education at the beginning of summer with reminders tailored to weather conditions helped KTRs adopt sun protection practices. This sun protection program for KTRs may be incorporated into the care provided by the nephrologist or transplant surgeon.

Physical activity and renal transplantation

Renal transplantation is burdened by high cardiovascular risk because of increased prevalence of traditional and disease-specific cardiovascular risk factors and, consequently, patients are affected by greater morbidity and mortality. In renal transplanted patients, healthy lifestyle and physical activity are recommended to improve overall morbidity and cardiovascular outcomes. According to METs (Metabolic Equivalent Task; i.e. the amount of energy consumed while sitting at rest), physical activities are classified as sedentary (<3.0 METs), of moderate-(3.0 to 5.9 METs) or vigorous-intensity (≥ 6.0 METs). Guidelines suggest for patients with chronic kidney disease an amount of physical activity of at least 30 minutes of moderate-intensity activity five times per week (min 450 MET-minutes/week). Data on physical activity in renal transplanted patients, however, are limited and have been mainly obtained by mean of non-objective methods. Available data suggest that physical activity is low either at the start or during renal transplantation and this may be associated with poor patient and graft outcomes. Therefore, in renal transplanted patients more data on physical activity obtained with objective, accelerometer-based methods are needed. In the meanwhile, physical activity have to be considered as an essential part of the medical care for renal transplanted recipients.

Completeness and satisfaction with the education and information received by patients immediately after kidney transplant: a mixed-models study

CONTEXT

Self-management is important in ensuring good clinical results in kidney transplant recipients. It was unclear whether the current education program at a single kidney transplant center sufficiently prepares recent transplant recipients for the many complex self-management tasks required.

OBJECTIVE

To evaluate the completeness of and the satisfaction with the current inpatient kidney transplant education program and to determine recipients' needs for information in the first months after discharge.

METHODS

We used a concurrent mixed-methods design, including 31 kidney transplant recipients who were assessed via a semistructured interview (qualitative part) and a questionnaire specifically designed for this study, consisting of 30 Likert-type and open-ended questions (quantitative part).

RESULTS

Kidney transplant patients reported having received extensive information about medication use after transplant surgery (antirejection medication, 93.5%). Information about healthy lifestyle (physical activity and rehabilitation, 54.8%), return to work (54.8%), and emotional coping (25.8%) was considered suboptimal, although most patients expressed a need for such information. Patients indicated a need for more concrete and practical information, not only during their hospital stay, but also in the long term after transplant.

CONCLUSIONS

This is the first mixed-models approach showing that our education program immediately after transplant focuses on the transfer of factual knowledge, which seems to insufficiently train patients in developing self-management skills. Updates of our program are warranted to overcome the gaps in the information provided, to provide more practical tips, and to repeat education in the long-term after the transplant surgery, tailored to the patients' needs.

National survey of provider opinions on controversial characteristics of liver transplant candidates

Candidate selection for liver transplantation presents challenging ethical issues that require balancing the principles of justice and utility. The goal of this study was to assess the opinions of U.S. transplant providers regarding the ways in which controversial medical and psychosocial characteristics influence patient eligibility for liver transplantation. An online, anonymous survey about adult patient characteristics was sent to providers (hepatologists, surgeons, psychiatrists, and social workers) at all 102 active adult liver transplant centers in the United States. A majority of the providers (251/444 or 56.5%) completed the survey. The providers were queried about 8 characteristics, and the 3 that were ranked most controversial were incarceration, marijuana use, and psychiatric diagnoses. Most providers identified a patient age ≥ 80 years (62.7%), a body mass index ≥ 45 kg/m2 (56.6%), and current incarceration with a lifetime sentence (54.7%) as absolute contraindications to liver transplantation. In a multivariate analysis, the identification of absolute contraindications varied significantly with the provider type, the center volume, and the geographical region. Less than half of the providers reported that their centers had written policies regarding most of the characteristics examined. In conclusion, providers differ significantly in their opinions on controversial patient characteristics and transplant contraindications. Along with a paucity of literature data on outcomes, these provider differences may play a role in the fact that many centers do not have formal policies for selecting patients with these characteristics. Evidence-based data on the outcomes of such patients are needed to guide the formation of written policies to better standardize eligibility criteria.

NUTORC-a transdisciplinary health services and outcomes research team in transplantation

The field of solid organ transplantation has historically concentrated research efforts on basic science and translational studies. However, there has been increasing interest in health services and outcomes research. The aim was to build an effective and sustainable, inter- and transdisciplinary health services and outcomes research team (NUTORC), that leveraged institutional strengths in social science, engineering, and management disciplines, coupled with an international recognized transplant program. In 2008, leading methodological experts across the university were identified and intramural funding was obtained for the NUTORC initiative. Inter- and transdisciplinary collaborative teams were created across departments and schools within the university. Within 3 years, NUTORC became fiscally sustainable, yielding more than tenfold return of the initial investment. Academic productivity included funding for 39 grants, publication of 60 manuscripts, and 166 national presentations. Sustainable educational opportunities for students were created. Inter- and transdisciplinary health services and outcomes research in transplant can be innovative and sustainable.

The association of community health indicators with outcomes for kidney transplant recipients in the United States

OBJECTIVE

To evaluate the association of community health indicators with outcomes for kidney transplant recipients.

DESIGN

Retrospective observational cohort study using multivariable Cox proportional hazards models.

SETTING

Transplant recipients in the United States from the Scientific Registry of Transplant Recipients merged with health indicators compiled from several national databases and the Centers for Disease Control and Prevention, including the National Center for Health Statistics, the Behavioral Risk Factor Surveillance System, and the National Center for Chronic Disease Prevention and Health Promotion.

PATIENTS

A total of 100 164 living and deceased donor adult (aged 18 years) kidney transplant recipients who underwent a transplant between January 1, 2004, and December 31, 2010.

MAIN OUTCOME MEASURES

Risk-adjusted time to posttransplant mortality and graft loss.

RESULTS

Multiple health indicators from recipients' residence were independently associated with outcomes, including low birth weight, preventable hospitalizations, inactivity rate, and smoking and obesity prevalence. Recipients in the highest-risk counties were more likely to be African American (adjusted odds ratio, 1.59, 95% CI, 1.51-1.68), to be younger (aged 18-39 years; 1.46; 1.32-1.60), to have lower educational attainment (<high school; 1.84; 1.62-2.08), and to have public insurance (1.46; 1.38-1.54). Proportions of recipients from higher-risk counties varied dramatically by center and region. There was an independent graded effect between health indicators and posttransplant mortality, including notable hazard associated with the highest-risk counties (adjusted hazard ratio, 1.26; 95% CI, 1.13-1.40).

CONCLUSIONS

In a national cohort of patients undergoing complex medical procedures, health indicators from patients' communities are strong independent predictors of all-cause mortality. Findings highlight the importance of community conditions for risk stratification of patients and development of individualized treatment protocols. Findings also demonstrate that standard risk adjustment does not capture important factors that may affect unbiased performance evaluations of transplant centers.