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Duncan S, Annunziato RA, Dunphy C, LaPointe Rudow D, Shneider BL, Shemesh E. A systematic review of immunosuppressant adherence interventions in transplant recipients: Decoding the streetlight effect. Pediatr Transplant 2018; 22:10.1111/petr.13086. [PMID: 29218760 PMCID: PMC5811374 DOI: 10.1111/petr.13086] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/23/2017] [Indexed: 12/23/2022]
Abstract
Non-adherence to immunosuppressant medications is an important risk factor for graft dysfunction. To evaluate the effectiveness of adherence-enhancing interventions, we reviewed adherence intervention studies in solid organ transplant recipients (all ages). Using the following databases: PsycINFO, PubMed, Scopus, and ScienceDirect, we identified 41 eligible studies. Only three non-randomized trials showed a possible positive effect on objective indicators of transplant outcomes (such as rejection, liver enzyme levels, kidney function). None of the 21 RCTs showed an improvement in transplant outcomes. Three studies showed a higher rate of adverse events in the intervention group as compared with controls, although this may be related to ascertainment bias. Improvement in adherence as measured indirectly (eg, with electronic monitoring devices) was not aligned with effects on transplant outcomes. We conclude that adherence interventions, to date, have largely been ineffective in improving transplant outcomes. To improve this track record, intervention efforts may wish to concentrate on non-adherent patients (rather than use convenience sampling, which excludes many of the patients who need the intervention), use direct measures of adherence to guide the interventions, and employ strategies that are intensive and yet engaging enough to ensure that non-adherent patients are able to participate.
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Affiliation(s)
- S Duncan
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, Kravis Children's Hospital, New York, NY, USA
- Department of Psychology, Fordham University, Bronx, NY, USA
| | - R A Annunziato
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, Kravis Children's Hospital, New York, NY, USA
- Department of Psychology, Fordham University, Bronx, NY, USA
| | - C Dunphy
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, Kravis Children's Hospital, New York, NY, USA
- Department of Psychology, Fordham University, Bronx, NY, USA
| | - D LaPointe Rudow
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, Kravis Children's Hospital, New York, NY, USA
| | - B L Shneider
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - E Shemesh
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, Kravis Children's Hospital, New York, NY, USA
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Kasiske BL, Asrani SK, Dew MA, Henderson ML, Henrich C, Humar A, Israni AK, Lentine KL, Matas AJ, Newell KA, LaPointe Rudow D, Massie AB, Snyder JJ, Taler SJ, Trotter JF, Waterman AD. The Living Donor Collective: A Scientific Registry for Living Donors. Am J Transplant 2017; 17:3040-3048. [PMID: 28520316 DOI: 10.1111/ajt.14365] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 04/20/2017] [Accepted: 05/07/2017] [Indexed: 01/25/2023]
Abstract
In the setting of an overall decline in living organ donation and new questions about long-term safety, a better understanding of outcomes after living donation has become imperative. Adequate information on outcomes important to donors may take many years to ascertain and may be evident only by comparing large numbers of donors with suitable controls. Previous studies have been unable to fully answer critical questions, primarily due to lack of appropriate controls, inadequate sample size, and/or follow-up duration that is too short to allow detection of important risks attributable to donation. The Organ Procurement and Transplantation Network does not follow donors long term and has no prospective control group with which to compare postdonation outcomes. There is a need to establish a national living donor registry and to prospectively follow donors over their lifetimes. In addition, there is a need to better understand the reasons many potential donors who volunteer to donate do not donate and whether the reasons are justified. Therefore, the US Health Resources and Services Administration asked the Scientific Registry of Transplant Recipients to establish a national registry to address these important questions. Here, we discuss the efforts, challenges, and opportunities inherent in establishing the Living Donor Collective.
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Affiliation(s)
- B L Kasiske
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, MN.,Department of Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - S K Asrani
- Transplant Hepatology, Baylor University Medical Center, Dallas, TX
| | - M A Dew
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - M L Henderson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - C Henrich
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, MN
| | - A Humar
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - A K Israni
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, MN.,Department of Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - K L Lentine
- Department of Medicine, Saint Louis University, St. Louis, MO
| | - A J Matas
- Department of Surgery, University of Minnesota, Minneapolis, MN
| | - K A Newell
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - D LaPointe Rudow
- Recanati Miller Transplantation Institute, Mount Sinai Hospital, New York, NY
| | - A B Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - J J Snyder
- Scientific Registry of Transplant Recipients, Minneapolis Medical Research Foundation, Minneapolis, MN
| | - S J Taler
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - J F Trotter
- Transplant Hepatology, Baylor University Medical Center, Dallas, TX
| | - A D Waterman
- David Geffen School of Medicine at UCLA, Kidney Transplant Program, Los Angeles, CA
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Hays R, Rodrigue JR, Cohen D, Danovitch G, Matas A, Schold J, LaPointe Rudow D. Financial Neutrality for Living Organ Donors: Reasoning, Rationale, Definitions, and Implementation Strategies. Am J Transplant 2016; 16:1973-81. [PMID: 27037542 DOI: 10.1111/ajt.13813] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 03/13/2016] [Accepted: 03/19/2016] [Indexed: 01/25/2023]
Abstract
In the United States, live organ donation can be a costly and burdensome undertaking for donors. While most donation-related medical expenses are covered, many donors still face lost wages, travel expenses, incidentals, and potential for future insurability problems. Despite widespread consensus that live donors (LD) should not be responsible for the costs associated with donation, little has changed to alleviate financial burdens for LDs in the last decade. To achieve this goal, the transplant community must actively pursue strategies and policies to eliminate unreimbursed out-of-pocket costs to LDs. Costs should be more appropriately distributed across all stakeholders; this will also make live donation possible for people who, in the current system, cannot afford to proceed. We propose the goal of LD "financial neutrality," offer an operational definition to include the coverage/reimbursement of all medical, travel, and lodging costs, along with lost wages, related to the act of donating an organ, and guidance for consideration of medical care coverage, and wage and other expense reimbursement. The intent of this report is to provide a foundation to inform discussion within the transplant community and to advance initiatives for policy and resource allocation.
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Affiliation(s)
- R Hays
- Transplant Center, University of Wisconsin Hospital and Clinics, Madison, WI
| | - J R Rodrigue
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - D Cohen
- Department of Medicine, Columbia University Medical Center, New York, NY
| | - G Danovitch
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA
| | - A Matas
- Department of Surgery, University of Minnesota Medical Center-Fairview, Minneapolis, MN
| | - J Schold
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - D LaPointe Rudow
- Recanati Miller Transplantation Institute, Mount Sinai Hospital, New York, NY
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Hays RE, LaPointe Rudow D, Dew MA, Taler SJ, Spicer H, Mandelbrot DA. The independent living donor advocate: a guidance document from the American Society of Transplantation's Living Donor Community of Practice (AST LDCOP). Am J Transplant 2015; 15:518-25. [PMID: 25612499 DOI: 10.1111/ajt.13001] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Revised: 08/18/2014] [Accepted: 08/30/2014] [Indexed: 01/25/2023]
Abstract
The independent living donor advocate (ILDA) serves a mandated and supportive role in the care of the living organ donor, yet qualifications and role requirements are not clearly defined. Guidance comes from Centers for Medicare and Medicaid Services (CMS) Conditions for Transplant Center Participation and interpretive guidelines, Organ Procurement and Transplantation Network (OPTN) Policy and CMS and OPTN site surveys, yet interpretation of regulations varies. Herein, the AST Living Donor Community of Practice (LDCOP) offers seven recommendations to clarify and optimize the ILDA role: (a) the ILDA must have a certain skill set rather than a specific profession, (b) the ILDA must be educated and demonstrate competence in core knowledge components, (c) the ILDA's primary role is to assess components of informed consent, (d) centers must develop a transparent system to define ILDA independence, (e) the ILDA should have a reporting structure outside the transplant center, (f) the ILDA's role should be integrated throughout the donor care continuum, (g) the ILDA role should include a narrow "veto power." We address controversies in ILDA implementation, and offer pathways to maximize benefits and minimize limitations of approaches that may each meet regulatory requirements but confer different practice benefits. We propose a research agenda to explore the impact of the ILDA.
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Affiliation(s)
- R E Hays
- Transplant Clinic, University of Wisconsin Hospital and Clinics, Madison, WI
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Ommen ES, LaPointe Rudow D, Medapalli RK, Schröppel B, Murphy B. When good intentions are not enough: obtaining follow-up data in living kidney donors. Am J Transplant 2011; 11:2575-81. [PMID: 22054024 DOI: 10.1111/j.1600-6143.2011.03815.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The Organ Procurement Transplant Network/United Network for Organ Sharing (OPTN/UNOS) has increased the amount of data collected before and after donation and increased the duration of donor follow-up to 2 years, yet there is evidence that reporting is incomplete. We examined the frequency of missing data in the OPTN/UNOS donor follow-up registry and found that reporting rates were low, particularly for donors who may have limited access to health care. We argue that a national donor follow-up registry is essential to ensure transparency in ascertaining long-term health outcomes among all living donors and in providing assessments of quality assurance within transplant programs. We have suggested approaches to strengthen the donor follow-up registry system. These include setting clear and high standards for follow-up reporting, a system of incentives and penalties that would motivate transplant centers to comply with these standards and would encourage donors to follow-up and lifelong follow-up reporting by primary care providers. We argue that the US government must provide funding to support a donor follow-up registry that can allow for meaningful and valid conclusions, in recognition of donors' public service and to maintain trust in the system of living organ donation.
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Affiliation(s)
- E S Ommen
- Department of Medicine, Mount Sinai School of Medicine, New York, NY, USA.
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Bernat JL, D'Alessandro AM, Port FK, Bleck TP, Heard SO, Medina J, Rosenbaum SH, Devita MA, Gaston RS, Merion RM, Barr ML, Marks WH, Nathan H, O'connor K, Rudow DL, Leichtman AB, Schwab P, Ascher NL, Metzger RA, Mc Bride V, Graham W, Wagner D, Warren J, Delmonico FL. Report of a National Conference on Donation after cardiac death. Am J Transplant 2006; 6:281-91. [PMID: 16426312 DOI: 10.1111/j.1600-6143.2005.01194.x] [Citation(s) in RCA: 356] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
A national conference on organ donation after cardiac death (DCD) was convened to expand the practice of DCD in the continuum of quality end-of-life care. This national conference affirmed the ethical propriety of DCD as not violating the dead donor rule. Further, by new developments not previously reported, the conference resolved controversy regarding the period of circulatory cessation that determines death and allows administration of pre-recovery pharmacologic agents, it established conditions of DCD eligibility, it presented current data regarding the successful transplantation of organs from DCD, it proposed a new framework of data reporting regarding ischemic events, it made specific recommendations to agencies and organizations to remove barriers to DCD, it brought guidance regarding organ allocation and the process of informed consent and it set an action plan to address media issues. When a consensual decision is made to withdraw life support by the attending physician and patient or by the attending physician and a family member or surrogate (particularly in an intensive care unit), a routine opportunity for DCD should be available to honor the deceased donor's wishes in every donor service area (DSA) of the United States.
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Abstract
Recurrence of hepatitis C is a significant problem after liver transplantation. This prospective study was done to assess the rate of recurrence and discuss two possible treatment modalities that have been successful in avoiding retransplantation. Twenty-one patients underwent orthotopic liver transplantation for hepatitis C at a metropolitan medical center over a 34-month period. The mean follow-up interval was 13.4 +/- 2.2 months (range 5-28 months). The patients were routinely evaluated with clinic visits and liver function tests, specifically total bilirubin, serum glutamic-oxaloacetic transaminase, and gamma-glutamyl transpeptidase. If values were elevated, the patient was admitted to the hospital for liver biopsy. Ten of the 21 patients demonstrated recurrence on biopsy. Two of 10 patients required no therapy. Interferon A was initiated in the remaining eight. Three of the eight patients had no significant response to interferon and were given intravenous ribavirin under an experimental protocol. Two of these three showed significant improvement in liver function values. The third died of chronic rejection. The incidence of recurrent hepatitis C after liver transplantation is significant. Many centers have had to resort to retransplantation. Our results show that with early detection and aggressive treatment with interferon and ribavirin, hepatitis C can be controlled and retransplantation may be avoided.
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Affiliation(s)
- P Harren
- New York University Medical Center, NY, USA
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