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Akbar AF, Zhou AL, Wang A, Feng ASN, Rizaldi AA, Ruck JM, Kilic A. Special Considerations for Advanced Heart Failure Surgeries: Durable Left Ventricular Devices and Heart Transplantation. J Cardiovasc Dev Dis 2024; 11:119. [PMID: 38667737 PMCID: PMC11050210 DOI: 10.3390/jcdd11040119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Revised: 04/08/2024] [Accepted: 04/13/2024] [Indexed: 04/28/2024] Open
Abstract
Heart transplantation and durable left ventricular assist devices (LVADs) represent two definitive therapies for end-stage heart failure in the modern era. Despite technological advances, both treatment modalities continue to experience unique risks that impact surgical and perioperative decision-making. Here, we review special populations and factors that impact risk in LVAD and heart transplant surgery and examine critical decisions in the management of these patients. As both heart transplantation and the use of durable LVADs as destination therapy continue to increase, these considerations will be of increasing relevance in managing advanced heart failure and improving outcomes.
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Affiliation(s)
| | | | | | | | | | | | - Ahmet Kilic
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins Hospital, 1800 Orleans Street, Zayed 7107, Baltimore, MD 21287, USA; (A.F.A.); (A.L.Z.); (A.W.); (A.S.N.F.); (A.A.R.); (J.M.R.)
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Kalra A, Ruck JM, Akbar AF, Zhou AL, Leng A, Casillan AJ, Ha JS, Merlo CA, Bush EL. Debunking the July Effect in lung transplantation recipients. JTCVS Open 2024; 18:376-399. [PMID: 38690438 PMCID: PMC11056481 DOI: 10.1016/j.xjon.2024.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 02/08/2024] [Indexed: 05/02/2024]
Abstract
Objective The "July Effect" is a theory that the influx of trainees from July to September negatively impacts patient outcomes. We aimed to study this theoretical phenomenon in lung transplant recipients given the highly technical nature of thoracic procedures. Methods Adult lung transplant hospitalizations were identified within the National Inpatient Sample (2005-2020). Recipients were categorized as academic Q1 (July to September) or Q2-Q4 (October to June). In-hospital mortality, operator-driven complications (pneumothorax, dehiscence including wound dehiscence, bronchial anastomosis, and others, and vocal cord/diaphragm paralysis, all 3 treated as a composite outcome), length of stay, and inflation-adjusted hospitalization charges were compared between both groups. Multivariable logistic regression was performed to assess the association between academic quarter and in-hospital mortality and operator-driven complications. The models were adjusted for recipient demographics and transplant characteristics. Subgroup analysis was performed between academic and nonacademic hospitals. Results Of 30,788 lung transplants, 7838 occurred in Q1 and 22,950 occurred in Q2-Q4. Recipient demographic and clinical characteristics were similar between groups. Dehiscence (n = 922, 4% vs n = 236, 3%), post-transplant cardiac arrest (n = 532, 2% vs n = 113, 1%), and pulmonary embolism (n = 712, 3% vs n = 164, 2%) were more common in Q2-Q4 versus Q1 recipients (all P < .05). Other operator-driven complications, in-hospital mortality, and resource use were similar between groups (P > .05). These inferences remained unchanged in adjusted analyses and on subgroup analyses of academic versus nonacademic hospitals. Conclusions The "July Effect" is not evident in US lung transplantation recipient outcomes during the transplant hospitalization. This suggests that current institutional monitoring systems for trainees across multiple specialties, including surgery, anesthesia, critical care, nursing, and others, are robust.
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Affiliation(s)
- Andrew Kalra
- Division of Thoracic Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pa
| | - Jessica M. Ruck
- Division of Thoracic Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Armaan F. Akbar
- Division of Thoracic Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Alice L. Zhou
- Division of Thoracic Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Albert Leng
- Division of Thoracic Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Alfred J. Casillan
- Division of Thoracic Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Jinny S. Ha
- Division of Thoracic Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Christian A. Merlo
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Errol L. Bush
- Division of Thoracic Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
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Zhou AL, Karius AK, Ruck JM, Shou BL, Larson EL, Casillan AJ, Ha JS, Shah PD, Merlo CA, Bush EL. Outcomes of Lung Transplant Candidates Aged ≥70 Years During the Lung Allocation Score Era. Ann Thorac Surg 2024; 117:725-732. [PMID: 37271446 PMCID: PMC10693648 DOI: 10.1016/j.athoracsur.2023.04.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 04/19/2023] [Accepted: 04/21/2023] [Indexed: 06/06/2023]
Abstract
BACKGROUND With the increasing age of lung transplant candidates, we studied waitlist and posttransplantation outcomes of candidates ≥70 years during the Lung Allocation Score era. METHODS Adult lung transplant candidates from 2005 to 2020 in the United Network for Organ Sharing database were included and stratified on the basis of age at listing into 18 to 59 years old, 60 to 69 years old, and ≥70 years old. Baseline characteristics, waitlist outcomes, and posttransplantation outcomes were assessed. RESULTS A total of 37,623 candidates were included (52.3% aged 18-59 years, 40.6% aged 60-69 years, 7.1% aged ≥70 years). Candidates ≥70 years were more likely than younger candidates to receive a transplant (81.9% vs 72.7% [aged 60-69 years] vs 61.6% [aged 18-59 years]) and less likely to die or to deteriorate on the waitlist within 1 year (9.1% vs 10.1% [aged 60-69 years] vs 12.2% [aged 18-59 years]; P < .001). Donors for older recipients were more likely to be extended criteria (75.7% vs 70.1% [aged 60-69 years] vs 65.7% [aged 18-59 years]; P < .001). Recipients ≥70 years were found to have lower rates of acute rejection (6.7% vs 7.4% [aged 60-69 years] vs 9.2% [aged 18-59 years]; P < .001) and prolonged intubation (21.7% vs 27.4% [aged 60-69 years] vs 34.5% [aged 18-59 years]; P < .001). Recipients aged ≥70 years had increased 1-year (adjusted hazard ratio [aHR], 1.19 [95% CI, 1.06-1.33]; P < .001), 3-year (aHR, 1.28 [95% CI, 1.18-1.39]; P < .001), and 5-year mortality (aHR, 1.29 [95% CI, 1.21-1.38]; P < .001) compared with recipients aged 60 to 69 years. CONCLUSIONS Candidates ≥70 years had favorable waitlist and perioperative outcomes despite increased use of extended criteria donors. Careful selection of candidates and postoperative surveillance may improve posttransplantation survival in this population.
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Affiliation(s)
- Alice L Zhou
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Alexander K Karius
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Jessica M Ruck
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Benjamin L Shou
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Emily L Larson
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Alfred J Casillan
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Jinny S Ha
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Pali D Shah
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Christian A Merlo
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Errol L Bush
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland.
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Zhou AL, Rizaldi AA, Akbar AF, Ruck JM, King EA, Kilic A. Outcomes following concomitant multiorgan heart transplantation from circulatory death donors: The United States experience. J Heart Lung Transplant 2024:S1053-2498(24)01535-3. [PMID: 38548240 DOI: 10.1016/j.healun.2024.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 09/11/2023] [Revised: 02/03/2024] [Accepted: 03/16/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND Donation after circulatory death (DCD) has reemerged as a method of expanding the donor heart pool. Given the high waitlist mortality of multiorgan heart candidates, we evaluated waitlist outcomes associated with willingness to consider DCD offers and post-transplant outcomes following DCD transplant for these candidates. METHODS We identified adult multiorgan heart candidates and recipients between January 1, 2020 and March 31, 2023 nationally. Among candidates that met inclusion criteria, we compared the cumulative incidence of transplant, with waitlist death/deterioration as a competing risk, by willingness to consider DCD offers. Among recipients of DCD versus brain death (DBD) transplants, we compared perioperative outcomes and post-transplant survival. RESULTS Of 1,802 heart-kidney, 266 heart-liver, and 440 heart-lung candidates, 15.8%, 12.4%, and 31.1%, respectively, were willing to consider DCD offers. On adjusted analysis, willingness to consider DCD offers was associated with higher likelihood of transplant for all multiorgan heart candidates and decreased likelihood of waitlist deterioration for heart-lung candidates. Of 1,100 heart-kidney, 173 heart-liver, and 159 heart-lung recipients, 5.4%, 2.3%, and 2.5%, respectively, received DCD organs. Recipients of DCD and DBD heart-kidney transplants had a similar likelihood of perioperative outcomes and 1-year survival. All other DCD multiorgan heart recipients have survived to the last follow-up. CONCLUSIONS Multiorgan heart candidates who were willing to consider DCD offers had favorable waitlist outcomes, and heart-kidney recipients of DCD transplants had similar post-transplant outcomes to recipients of DBD transplants. We recommend the use of DCD organs to increase the donor pool for these high-risk candidates.
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Affiliation(s)
- Alice L Zhou
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Alexandra A Rizaldi
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Armaan F Akbar
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Jessica M Ruck
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Elizabeth A King
- Division of Transplant Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Ahmet Kilic
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland.
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Kalra A, Ruck JM, Zhou AL, Akbar AF, Shou BL, Casillan AJ, Ha JS, Merlo CA, Bush EL. Bigger pies, bigger slices: Increased hospitalization costs for lung transplantation recipients in the non-donation service area allocation era. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00103-X. [PMID: 38678473 DOI: 10.1016/j.jtcvs.2024.01.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 01/23/2024] [Accepted: 01/24/2024] [Indexed: 05/01/2024]
Abstract
OBJECTIVE On November 24, 2017, lung transplant allocation switched from donation service area to a 250-nautical mile radius policy to improve equity in access to lung transplantation. Given the growing consideration of healthcare costs, we evaluated changes in hospitalization costs after this policy change. METHODS Lung transplant hospitalizations were identified within the National Inpatient Sample from 2005 to 2020. Recipients were categorized as donation service area era (August 2015 to October 2017) or non-donation service area era (December 2017 to February 2020). Median total hospitalization costs (inflation adjusted) were compared by era nationally and regionally. Multivariable generalized linear regression was performed to determine if the removal of the donation service area was associated with total hospitalization costs. The model was adjusted for recipient demographics, Charlson Comorbidity Index, hospitalization region, transplant type (single, double), and use of extracorporeal membrane oxygenation, ex vivo lung perfusion, and mechanical ventilation. RESULTS We analyzed 12,985 lung transplant recipients (median age of 61 years, 66% were male): 7070 in the donation service area era and 5915 in the non-donation service area era. Demographics were not different between recipients in both eras. Non-donation service area era recipients had greater extracorporeal membrane oxygenation use, mechanical ventilation (<24 hours), and longer length of stay than donation service area era recipients. Median total hospitalization costs for non-donation service area versus donation service area era recipients increased by $24,198 ($157,964 vs $182,162, percentage change = 15.32%, P < .001). Median costs increased in East North Central ($42,281) and Mountain ($35,521) regions (both P < .01). After adjustment, median costs for non-donation service area versus donation service area era recipients still increased ($19,168, 95% CI, 145-38,191, P = .048). CONCLUSIONS Hospitalization costs for lung transplant hospitalizations have increased from 2015 to 2020. The transition from donation service area-based allocation to the non-donation service area system may have contributed to this increase after 2017 by increasing access to transplant for sicker recipients.
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Affiliation(s)
- Andrew Kalra
- Division of Thoracic Surgery, Johns Hopkins University School of Medicine, Baltimore, Md; Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pa
| | - Jessica M Ruck
- Division of Thoracic Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Alice L Zhou
- Division of Thoracic Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Armaan F Akbar
- Division of Thoracic Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Benjamin L Shou
- Division of Thoracic Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Alfred J Casillan
- Division of Thoracic Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Jinny S Ha
- Division of Thoracic Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Christian A Merlo
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Errol L Bush
- Division of Thoracic Surgery, Johns Hopkins University School of Medicine, Baltimore, Md.
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Chen Y, Li Y, Liu Y, Kim B, Ruck JM, Clark-Cutaia MN, Mathur A, Purnell TS, Thorpe RJ, Crews DC, Szanton SL, Segev DL, McAdams-DeMarco M. Residential Racial and Ethnic Segregation and Post-Kidney Transplant Dementia, Allograft Loss, and Mortality. Am J Kidney Dis 2024:S0272-6386(24)00627-9. [PMID: 38447706 DOI: 10.1053/j.ajkd.2024.01.518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 01/05/2024] [Accepted: 01/08/2024] [Indexed: 03/08/2024]
Affiliation(s)
- Yusi Chen
- Department of Surgery, NYU Grossman School of Medicine and NYU Langone Health, New York, New York
| | - Yiting Li
- Department of Surgery, NYU Grossman School of Medicine and NYU Langone Health, New York, New York
| | - Yi Liu
- Department of Surgery, NYU Grossman School of Medicine and NYU Langone Health, New York, New York
| | - Byoungjun Kim
- Department of Surgery, NYU Grossman School of Medicine and NYU Langone Health, New York, New York; Department of Population Health, NYU Grossman School of Medicine and NYU Langone Health, New York, New York
| | - Jessica M Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Aarti Mathur
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Tanjala S Purnell
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Roland J Thorpe
- Hopkins Center for Health Disparities Solutions, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Deidra C Crews
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sarah L Szanton
- Johns Hopkins University School of Nursing, Baltimore, Maryland
| | - Dorry L Segev
- Department of Surgery, NYU Grossman School of Medicine and NYU Langone Health, New York, New York; Department of Population Health, NYU Grossman School of Medicine and NYU Langone Health, New York, New York
| | - Mara McAdams-DeMarco
- Department of Surgery, NYU Grossman School of Medicine and NYU Langone Health, New York, New York; Department of Population Health, NYU Grossman School of Medicine and NYU Langone Health, New York, New York.
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Zhou AL, Jenkins RT, Ruck JM, Shou BL, Larson EL, Casillan AJ, Ha JS, Merlo CA, Bush EL. Outcomes of Recipients Aged 65 Years and Older Bridged to Lung Transplant With Extracorporeal Membrane Oxygenation. ASAIO J 2024; 70:230-238. [PMID: 37939695 PMCID: PMC10922625 DOI: 10.1097/mat.0000000000002092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplant (BTT) has been used for critically ill candidates with excellent outcomes, but data on this strategy in older recipients remain limited. We compared outcomes of no BTT, mechanical ventilation (MV)-only BTT, and ECMO BTT in recipients of greater than or equal to 65 years. Lung-only recipients of greater than or equal to 65 years in the United Network for Organ Sharing database between 2008 and 2022 were included and stratified by bridging strategy. Of the 9,936 transplants included, 226 (2.3%) were MV-only BTT and 159 (1.6%) were ECMO BTT. Extracorporeal membrane oxygenation BTT recipients were more likely to have restrictive disease pathology, had higher median lung allocation score, and spent fewer days on the waitlist (all p < 0.001). Compared to no-BTT recipients, ECMO BTT recipients were more likely to be intubated or on ECMO at 72 hours posttransplant and had longer hospital lengths of stay (all p < 0.001). Extracorporeal membrane oxygenation BTT recipients had increased risk of 3 years mortality compared to both no-BTT (adjusted hazard ratio [aHR] = 1.48 [95% confidence interval {CI}: 1.14-1.91], p = 0.003) and MV-only recipients (aHR = 1.50 [95% CI: 1.08-2.07], p = 0.02). Overall, we found that ECMO BTT in older recipients is associated with inferior posttransplant outcomes compared to MV-only or no BTT, but over half of recipients remained alive at 3 years posttransplant.
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Affiliation(s)
- Alice L. Zhou
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital
| | - Reed T. Jenkins
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital
| | - Jessica M. Ruck
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital
| | - Benjamin L. Shou
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital
| | - Emily L. Larson
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital
| | - Alfred J. Casillan
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital
| | - Jinny S. Ha
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital
| | - Christian A. Merlo
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins Hospital
| | - Errol L. Bush
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital
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Kaplow K, Ruck JM, Levan ML, Thomas AG, Stewart D, Massie AB, Sung HC, Pisano SF, Sidoti C, Segev DL, Sinacore J, Waterman AD. National Attitudes Toward Living Kidney Donation in the United States: Results of a Public Opinion Survey. Kidney Med 2024; 6:100788. [PMID: 38435064 PMCID: PMC10906424 DOI: 10.1016/j.xkme.2023.100788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024] Open
Abstract
Rationale & Objective Understanding national attitudes about living kidney donation will enable us to identify and address existing disincentives to living kidney donation. We performed a national survey to describe living kidney donation perceptions, perceived factors that affect the willingness to donate, and analyzed differences by demographic subgroups. Study Design The survey items captured living kidney donation awareness, living kidney donation knowledge, willingness to donate, and barriers and facilitators to living kidney donation. Setting & Population We surveyed 802 US adults (aged 25-65 years) in June 2021, randomly selected from an online platform with diverse representation. Analytical Approach We developed summed, scaled indices to assess the association between the living kidney donation knowledge (9 items) and the willingness to donate (8 items) to self-reported demographic characteristics and other variables of interest using analysis of variance. All other associations for categorical questions were calculated using Pearson's χ2 and Fisher exact tests. We inductively evaluated free-text responses to identify additional barriers and facilitators to living kidney donation. Results Most (86.6%) of the respondents reported that they might or would definitely consider donating a kidney while they were still living. Barriers to living kidney donation included concerns about the risk of the surgery, paying for medical expenses, and potential health effects. Facilitators to living kidney donation included having information on the donation surgery's safety, knowing that the donor would not have to pay for medical expenses related to the donation, and hearing living kidney donation success stories. Awareness of the ability to participate in kidney-paired donation was associated with a higher willingness to donate. Limitations Potential for selection bias resulting from the use of survey panels and varied incentive amounts, and measurement error related to respondents' attention level. Conclusions Most people would consider becoming a living kidney donor. Increased rates of living kidney donation may be possible with investment in culturally competent educational interventions that address risks associated with donating, policies that reduce financial disincentives, and communication campaigns that raise awareness of kidney-paired donation and living kidney donation.
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Affiliation(s)
- Katya Kaplow
- Department of Surgery, New York University Langone, New York, New York
| | - Jessica M. Ruck
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Macey L. Levan
- Department of Surgery, New York University Langone, New York, New York
| | - Alvin G. Thomas
- Department of Surgery, New York University Langone, New York, New York
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Darren Stewart
- Department of Surgery, New York University Langone, New York, New York
| | - Allan B. Massie
- Department of Surgery, New York University Langone, New York, New York
| | - Hannah C. Sung
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sarah F. Pisano
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Carolyn Sidoti
- Department of Surgery, New York University Langone, New York, New York
| | - Dorry L. Segev
- Department of Surgery, New York University Langone, New York, New York
| | | | - Amy D. Waterman
- Department of Surgery, Houston Methodist Hospital, Houston, Texas
- Department of Surgery, J.C. Walter Jr Transplant Center, Houston Methodist Hospital, Houston, Texas
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9
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Florissi I, Chidi AP, Liu Y, Ruck JM, Mauney C, McAdams-DeMarco M, Merlo CA, Shah P, Stewart DE, Segev DL, Bush EL. Racial Disparities in Waiting List Outcomes of Patients Listed for Lung Transplantation. Ann Thorac Surg 2024; 117:619-626. [PMID: 37673311 PMCID: PMC10924067 DOI: 10.1016/j.athoracsur.2023.07.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 07/08/2023] [Accepted: 07/31/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND The Lung Allocation Score, implemented in 2005, prioritized lung transplant candidates by medical urgency rather than waiting list time and was expected to improve racial disparities in transplant allocation. We evaluated whether racial disparities in lung transplant persisted after 2005. METHODS We identified all wait-listed adult lung transplant candidates in the United States from 2005 through 2021 using the Scientific Registry of Transplant Recipients. We evaluated the association between race and receipt of a transplant by using a multivariable competing risk regression model adjusted for demographics, socioeconomic status, Lung Allocation Score, clinical measures, and time. We evaluated interactions between race and age, sex, socioeconomic status, and Lung Allocation Score. RESULTS We identified 33,158 candidates on the lung transplant waiting list between 2005 and 2021: 27,074 White (82%), 3350 African American (10%), and 2734 Hispanic (8%). White candidates were older, had higher education levels, and had lower Lung Allocation Scores (P < .001). After multivariable adjustment, African American and Hispanic candidates were less likely to receive lung transplants than White candidates (African American: adjusted subhazard ratio, 0.86; 95% CI, 0.82-0.91; Hispanic: adjusted subhazard ratio, 0.82; 95% CI, 0.78-0.87). Lung transplant was significantly less common among Hispanic candidates aged >65 years (P = .003) and non-White candidates from higher-poverty communities (African-American: P = .013; Hispanic: P =.0036). CONCLUSIONS Despite implementation of the Lung Allocation Score, racial disparities persisted for wait-listed African American and Hispanic lung transplant candidates and differed by age and poverty status. Targeted interventions are needed to ensure equitable access to this life-saving intervention.
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Affiliation(s)
- Isabella Florissi
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alexis P Chidi
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Yi Liu
- Department of Surgery, New York University Grossman School of Medicine, New York, New York
| | - Jessica M Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Carrinton Mauney
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mara McAdams-DeMarco
- Department of Surgery, New York University Grossman School of Medicine, New York, New York
| | - Christian A Merlo
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Pali Shah
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Darren E Stewart
- Department of Surgery, New York University Grossman School of Medicine, New York, New York
| | - Dorry L Segev
- Department of Surgery, New York University Grossman School of Medicine, New York, New York
| | - Errol L Bush
- Division of Thoracic Surgery, Johns Hopkins Hospital, Baltimore, Maryland.
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10
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Ruck JM, Chu NM, Liu Y, Li Y, Chen Y, Mathur A, Carlson MC, Crews DC, Chodosh J, Segev DL, McAdams-DeMarco M. Association of Postoperative Delirium With Incident Dementia and Graft Outcomes Among Kidney Transplant Recipients. Transplantation 2024; 108:530-538. [PMID: 37643030 PMCID: PMC10840878 DOI: 10.1097/tp.0000000000004779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
BACKGROUND Kidney transplant (KT) recipients have numerous risk factors for delirium, including those shared with the general surgical population (eg, age and major surgery) and transplant-specific factors (eg, neurotoxic immunosuppression medications). Evidence has linked delirium to long-term dementia risk in older adults undergoing major surgery. We sought to characterize dementia risk associated with post-KT delirium. METHODS Using the United States Renal Data System datasets, we identified 35 800 adult first-time KT recipients ≥55 y. We evaluated risk factors for delirium using logistic regression. We evaluated the association between delirium and incident dementia (overall and by subtype: Alzheimer's, vascular, and other/mixed-type), graft loss, and death using Fine and Gray's subhazards models and Cox regression. RESULTS During the KT hospitalization, 0.9% of recipients were diagnosed with delirium. Delirium risk factors included age (OR = 1.40, 95% CI, 1.28-1.52) and diabetes (OR = 1.38, 95% CI, 1.10-1.73). Delirium was associated with higher risk of death-censored graft loss (aHR = 1.52, 95% CI, 1.12-2.05) and all-cause mortality (aHR = 1.53, 95% CI, 1.25-1.89) at 5 y post-KT. Delirium was also associated with higher risk of dementia (adjusted subhazard ratio [aSHR] = 4.59, 95% CI, 3.48-6.06), particularly vascular dementia (aSHR = 2.51, 95% CI, 1.01-6.25) and other/mixed-type dementia (aSHR = 5.58, 95% CI, 4.24-7.62) subtypes. The risk of all-type dementia associated with delirium was higher for younger recipients aged between 55 and 64 y ( Pinteraction = 0.01). CONCLUSIONS Delirium is a strong risk factor for subsequent diagnosis of dementia among KT recipients, particularly those aged between 55 and 64 y at the time of transplant. Patients experiencing posttransplant delirium might benefit from early interventions to enhance cognitive health and surveillance for cognitive impairment to enable early referral for dementia care.
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Affiliation(s)
- Jessica M Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Nadia M Chu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Yi Liu
- Department of Surgery, New York University Grossman School of Medicine and Langone Health, New York, NY
| | - Yiting Li
- Department of Surgery, New York University Grossman School of Medicine and Langone Health, New York, NY
| | - Yusi Chen
- Department of Surgery, New York University Grossman School of Medicine and Langone Health, New York, NY
| | - Aarti Mathur
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michelle C Carlson
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Deidra C Crews
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Joshua Chodosh
- Department of Population Health, New York University Grossman School of Medicine and Langone Health, New York, NY
- Department of Medicine, New York University Grossman School of Medicine and Langone Health, New York, NY
| | - Dorry L Segev
- Department of Surgery, New York University Grossman School of Medicine and Langone Health, New York, NY
- Department of Population Health, New York University Grossman School of Medicine and Langone Health, New York, NY
| | - Mara McAdams-DeMarco
- Department of Surgery, New York University Grossman School of Medicine and Langone Health, New York, NY
- Department of Population Health, New York University Grossman School of Medicine and Langone Health, New York, NY
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11
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Zhou AL, Leng A, Ruck JM, Akbar AF, Desai NM, King EA. Kidney Donation After Circulatory Death Using Thoracoabdominal Normothermic Regional Perfusion: The Largest Report of the United States Experience. Transplantation 2024; 108:516-523. [PMID: 37691154 PMCID: PMC10840803 DOI: 10.1097/tp.0000000000004801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
BACKGROUND Thoracoabdominal normothermic regional perfusion (TA-NRP) has been increasingly used for donation after circulatory death (DCD) procurements in the United States. We present the largest report of outcomes of kidney transplants performed using DCD donor grafts perfused with TA-NRP. METHODS Adult DCD kidney transplants between 2020 and 2022 in the United Network for Organ Sharing database were included. Donors with ≥50 min between asystole and aortic cross-clamp time in which the heart was also transplanted were considered TA-NRP donors. All other donors were considered direct recovery donors. Multivariable regressions were used to assess delayed graft function, as well as posttransplant survival and all-cause graft failure at 30, 90, and 180 d. A propensity-matched analysis of cohorts matched on donor Kidney Donor Profile Index was performed. RESULTS Of the 16 140 total DCD kidney transplants performed during the study period, 306 (1.9%) used TA-NRP. TA-NRP donors were younger ( P < 0.001) and had lower Kidney Donor Profile Index ( P < 0.001) compared with direct recovery donors. Recipients receiving grafts recovered using TA-NRP were younger ( P < 0.001) and more likely to be blood group O ( P < 0.001). Transplants using TA-NRP had lower likelihood of delayed graft function (adjusted odds ratio 0.22 [95% confidence interval, 0.15-0.31], P < 0.001) but similar 180-d survival ( P = 0.8) and all-cause graft failure ( P = 0.3) as transplants using direct recovery grafts. These inferences were unchanged on propensity-matched analysis. CONCLUSIONS Our results demonstrate that kidney transplants using TA-NRP DCD allografts have positive short-term mortality and graft survival outcomes, with significantly decreased rates of delayed graft function compared with direct recovery DCD grafts.
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Affiliation(s)
- Alice L. Zhou
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Albert Leng
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Jessica M. Ruck
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Armaan F. Akbar
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Niraj M. Desai
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
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12
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Ruck JM, Zhou AL, Florissi I, Ha JS, Shah PD, Massie AB, Segev DL, Merlo CA, Bush EL. Uptake and 1-year outcomes of lung transplantation for COVID-19. J Thorac Cardiovasc Surg 2024; 167:549-555.e1. [PMID: 37286074 PMCID: PMC10240904 DOI: 10.1016/j.jtcvs.2023.05.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Received: 01/10/2023] [Revised: 05/25/2023] [Accepted: 05/27/2023] [Indexed: 06/09/2023]
Abstract
OBJECTIVE End-stage lung disease from severe COVID-19 infection is an increasingly common indication for lung transplantation (LT), but there are limited data on outcomes. We evaluated 1-year COVID-19 LT outcomes. METHODS We identified all adult US LT recipients January 2020 to October 2022 in the Scientific Registry for Transplant Recipients, using diagnosis codes to identify recipients transplanted for COVID-19. We used multivariable regression to compare in-hospital acute rejection, prolonged ventilator support, tracheostomy, dialysis, and 1-year mortality between COVID-19 and non-COVID-19 recipients, adjusting for donor, recipient, and transplant characteristics. RESULTS LT for COVID-19 increased from 0.8% to 10.7% of total LT volume during 2020 to 2021. The number of centers performing LT for COVID-19 increased from 12 to 50. Recipients transplanted for COVID-19 were younger; were more likely to be male and Hispanic; were more likely to be on a ventilator, extracorporeal membrane oxygenation support, and dialysis pre-LT; were more likely to receive bilateral LT; and had higher lung allocation score and shorter waitlist time than other recipients (all P values < .001). COVID-19 LT had higher risk of prolonged ventilator support (adjusted odds ratio, 2.28; P < .001), tracheostomy (adjusted odds ratio 5.3; P < .001), and longer length of stay (median, 27 vs 19 days; P < .001). Risk of in-hospital acute rejection (adjusted odds ratio, 0.99; P = .95) and 1-year mortality (adjusted hazard ratio, 0.73; P = .12) were similar for COVID-19 LTs and LTs for other indications, even accounting for center-level differences. CONCLUSIONS COVID-19 LT is associated with higher risk of immediate postoperative complications but similar risk of 1-year mortality despite more severe pre-LT illness. These encouraging results support the ongoing use of LT for COVID-19-related lung disease.
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Affiliation(s)
- Jessica M Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Alice L Zhou
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Isabella Florissi
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Jinny S Ha
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Pali D Shah
- Division of Pulmonology, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Allan B Massie
- Department of Surgery, NYU Langone School of Medicine, New York, NY; Department of Population Health, New York University Grossman School of Medicine and Langone Health, New York, NY
| | - Dorry L Segev
- Department of Surgery, NYU Langone School of Medicine, New York, NY; Department of Population Health, New York University Grossman School of Medicine and Langone Health, New York, NY; Scientific Registry of Transplant Recipients, Minneapolis, Minn
| | - Christian A Merlo
- Division of Pulmonology, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Errol L Bush
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md.
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13
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Casillan AJ, Zhou AL, Ruck JM, Larson EL, Etchill EW, Ha JS, Shah PD, Merlo CA, Bush EL. The effect of allograft ischemic time on outcomes following bilateral, single, and reoperative lung transplantation. J Thorac Cardiovasc Surg 2024; 167:556-565.e8. [PMID: 37286076 DOI: 10.1016/j.jtcvs.2023.05.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 04/24/2023] [Accepted: 05/24/2023] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To determine whether allograft ischemic times affect outcomes following bilateral, single, and redo lung transplantation. METHODS A nationwide cohort of lung transplant recipients from 2005 through 2020 was examined using the Organ Procurement and Transplantation Network registry. The effects of standard (<6 hours) and extended (≥6 hours) ischemic times on outcomes following primary bilateral (n = 19,624), primary single (n = 688), redo bilateral (n = 8461), and redo single (n = 449) lung transplantation were analyzed. A priori subgroup analysis was performed in the primary and redo bilateral-lung transplant cohorts by further stratifying the extended ischemic time group into mild (≥6 and <8 hours), moderate (≥8 and <10 hours), and long (≥10 hours) subgroups. Primary outcomes included 30-day mortality, 1-year mortality, intubation at 72 hours' posttransplant, extracorporeal membrane oxygenation (ECMO) support at 72 hours' posttransplant, and a composite variable of intubation or ECMO at 72 hours' posttransplant. Secondary outcomes included acute rejection, postoperative dialysis, and hospital length of stay. RESULTS Recipients of allografts with ischemic times ≥6 hours experienced increased 30-day and 1-year mortality following primary bilateral-lung transplantation, but increased mortality was not observed following primary single, redo bilateral, or redo single-lung transplants. Extended ischemic times correlated with prolonged intubation or increased postoperative ECMO support in the primary bilateral, primary single, and redo bilateral-lung transplant cohorts but did not affect these outcomes following redo single-lung transplantation. CONCLUSIONS Since prolonged allograft ischemia correlates with worse transplant outcomes, the decision to use donor lungs with extended ischemic times must consider the specific benefits and risks associated with individual recipient factors and institutional expertise.
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Affiliation(s)
- Alfred J Casillan
- Division of Thoracic Surgery, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Md
| | - Alice L Zhou
- Division of Thoracic Surgery, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Md
| | - Jessica M Ruck
- Division of Thoracic Surgery, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Md
| | - Emily L Larson
- Division of Thoracic Surgery, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Md
| | - Eric W Etchill
- Division of Thoracic Surgery, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Md
| | - Jinny S Ha
- Division of Thoracic Surgery, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Md
| | - Pali D Shah
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, The Johns Hopkins Hospital, Baltimore, Md
| | - Christian A Merlo
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, The Johns Hopkins Hospital, Baltimore, Md
| | - Errol L Bush
- Division of Thoracic Surgery, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Md.
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14
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Teles MS, Ruck JM, Jefferis A, Helmy S, Oh ES, Murriel EC, Lai JC, King EA. A pragmatic tool to screen for pre-transplant cognitive impairment among potential candidates for liver transplant. Clin Transplant 2024; 38:e15232. [PMID: 38289890 DOI: 10.1111/ctr.15232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 12/01/2023] [Accepted: 12/10/2023] [Indexed: 02/01/2024]
Abstract
INTRODUCTION Cognitive impairment (CI) among liver transplant (LT) candidates is associated with increased risk of waitlist mortality and inferior outcomes. While formal neurocognitive evaluation is the gold standard for CI diagnosis, the Montreal Cognitive Assessment (MoCA) is often used for first-line cognitive screening. However, MoCA requires specialized training and may be too lengthy for a busy evaluation appointment. An alternate approach may be the Quick Dementia Rating System (QDRS), which is patient- and informant-based and can be administered quickly. We compared potential LT candidates identified by MoCA and QDRS as potentially benefiting from further formal cognitive evaluation. METHODS We identified 46 potential LT candidates enrolled at a single center of a prospective, observational cohort study who were administered MoCA and QDRS during transplant evaluation (12/2021-12/2022). Scores were dichotomized as (1) normal versus abnormal and (2) normal/mild impairment versus more-than-mild impairment. We calculated sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of QDRS compared to MoCA. RESULTS By MoCA, this population had a prevalence of 48% normal cognition, 48% mild, 4% moderate, and 0% severe impairment. This was categorized as 96% normal/mild and 4% more-than-mild impairment. When comparing to MoCA cognitive screening, QDRS had a sensitivity of 61%, specificity of 56%, NPV of 56%, and PPV of 61%. When identifying more-than-mild impairment, QDRS had a sensitivity of 100%, specificity of 73%, NPV of 100%, and PPV of 10%. CONCLUSION The high sensitivity and NPV of QDRS in identifying more-than-mild impairment suggests it could identify potential LT candidates who would benefit from further formal cognitive evaluation. The ability to administer QDRS quickly and remotely makes it a pragmatic option for pre-transplant screening.
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Affiliation(s)
- Mayan S Teles
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jessica M Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Alexa Jefferis
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sherif Helmy
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Esther S Oh
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Emily C Murriel
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jennifer C Lai
- Department of Medicine, University of California San Francisco Medical Center, San Francisco, California, USA
| | - Elizabeth A King
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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15
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Berry K, Ruck JM, Barry F, Shui AM, Cortella A, Kent D, Seetharaman S, Wong R, VandeVrede L, Lai JC. Prevalence of cognitive impairment in liver transplant recipients. Clin Transplant 2024; 38:e15229. [PMID: 38113284 PMCID: PMC10842727 DOI: 10.1111/ctr.15229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 11/06/2023] [Accepted: 12/10/2023] [Indexed: 12/21/2023]
Abstract
Liver transplant (LT) recipients have a high burden of cognitive impairment risk factors identified in other populations, yet little work has explored cognition in the United States LT population. We characterized prevalence of cognitive impairment (CI) in LT recipients pre-LT and ≥3 months post-LT. Adult LT recipients with cirrhosis but without active pre-LT hepatic encephalopathy (HE) were screened for CI using the Montreal Cognitive Assessment (MoCA) for CI (MoCA <24) both pre-LT and ≥3 months post-LT. The association between cognitive performance and recipient characteristics was assessed using logistic regression. Of 107 LT recipients, 36% had pre-LT CI and 27% had post-LT CI [median (Q1-Q3) MoCA 26 (23-28)]. Each 1-point increase in pre-LT MoCA was associated with 26% lower odds of post-LT cognitive impairment (aOR .74, 95% CI .63-.87, p < .001), after adjusting for recipient age, history of HE, and time since LT. In this study of cirrhosis recipients without active pre-LT HE, cognitive impairment was prevalent before LT and remained prevalent ≥3 months after LT (27%), long after effects of portal hypertension on cognition would be expected to have resolved. Our data expose an urgent need for more comprehensive neurologic examination of LT recipients to better identify, characterize, and address predictors of post-LT cognitive impairment.
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Affiliation(s)
- Kacey Berry
- Memory and Aging Center, Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Jessica M Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Fawzy Barry
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California San Francisco, San Francisco, California, USA
| | - Amy M Shui
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California San Francisco, San Francisco, California, USA
| | - Aly Cortella
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California San Francisco, San Francisco, California, USA
| | - Dorothea Kent
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California San Francisco, San Francisco, California, USA
| | - Srilakshmi Seetharaman
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California San Francisco, San Francisco, California, USA
| | - Randi Wong
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California San Francisco, San Francisco, California, USA
| | - Lawren VandeVrede
- Memory and Aging Center, Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Jennifer C Lai
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California San Francisco, San Francisco, California, USA
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16
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Ruck JM, Shui AM, Jefferis AA, Rojo AD, Rahimi RS, Ganger DR, Verna EC, Kappus M, Ladner DP, Segev DL, Volk M, Tevar A, King EA, Lai JC. Association of body mass index with post-liver transplant outcomes. Clin Transplant 2024; 38:e15205. [PMID: 38041450 PMCID: PMC10918560 DOI: 10.1111/ctr.15205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 08/18/2023] [Accepted: 11/19/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND Patients with obesity have inferior outcomes after general surgery procedures, but studies evaluating post-liver transplant (LT) outcomes have been limited by small sample sizes or lack of granularity of outcomes. We evaluated the relationship between obesity and post-LT outcomes, including those observed in other populations to be obesity-related. METHODS Included were 1357 LT recipients prospectively enrolled in the ambulatory pre-LT setting at 8 U.S. CENTERS Recipient were categorized by body mass index (BMI, kg/m2 ): non-obese (BMI < 30), class 1 obesity (BMI 30-<35), and classes 2-3 obesity (BMI ≥ 35). Post-transplant complications were compared by BMI using Chi-square and rank-sum testing, logistic regression, Kaplan-Meier curves, and Cox regression. RESULTS Classes 2-3 obesity was associated with higher adjusted odds than non-obesity of venous thrombosis [adjusted odds ratio (aOR) 2.06, 95% CI 1.01-4.23, p = .047] and wound dehiscence (aOR 2.45, 95% CI 1.19-5.06, p = .02). Compared with non-obese recipients, post-LT hospital stay was significantly longer for recipients with classes 2-3 obesity [p = .01; median (Q1-Q3) 9 (6-14) vs. 8 (6-12) days) or class 1 obesity [p = .002; 9 (6-14) vs. 8 (6-11) days]. Likelihood of ICU readmission, infection, discharge to a non-home facility, rejection, 30-day readmission, and 1-year readmission were similar across BMI categories (all p > .05). CONCLUSION Compared to non-obese recipients, obese recipients had similar post-LT survival but longer hospital stay and higher likelihood of wound dehiscence and venous thrombosis. These findings underscore that obesity alone should not preclude LT, but recipients with obesity should be monitored for obesity-related complications such as wound dehiscence and venous thrombosis.
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Affiliation(s)
- Jessica M. Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Amy M. Shui
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Alexis A. Jefferis
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Andres Duarte Rojo
- Center for Liver Diseases, Thomas A. Starzl Transplantation Institute, Pittsburgh Liver Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Robert S. Rahimi
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Baylor Scott and White Health, Dallas, Texas, USA
| | - Daniel R. Ganger
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern Medicine, Chicago, Illinois, USA
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Elizabeth C. Verna
- Center for Liver Disease and Transplantation, Columbia University Irving Medical Center, New York, New York, USA
| | - Matthew Kappus
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Daniela P. Ladner
- Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Division of Transplantation, Department of Surgery, Northwestern Medicine, Chicago, Illinois, USA
| | - Dorry L. Segev
- Department of Surgery, New York University Grossman School of Medicine and Langone Health, New York, New York, USA
- Department of Population Health, New York University Grossman School of Medicine and Langone Health, New York, New York, USA
| | - Michael Volk
- Division of Gastroenterology & Hepatology, and Transplantation Institute, Loma Linda University Health, Loma Linda, California, USA
| | - Amit Tevar
- Department of Medicine, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Elizabeth A. King
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jennifer C. Lai
- Department of Medicine, University of California San Francisco School of Medicine, San Francisco, California, USA
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Ruck JM, Broderick SR. Neoadjuvant and Adjuvant Pembrolizumab for the Treatment of Early-Stage Resectable Non-small Cell Lung Cancer An Editorial Regarding the Interim Data Analysis of the KEYNOTE-671 Phase III Trial of Neoadjuvant and Adjuvant Pembrolizumab. Ann Surg Oncol 2024; 31:4-5. [PMID: 37884698 DOI: 10.1245/s10434-023-14356-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 09/13/2023] [Indexed: 10/28/2023]
Affiliation(s)
- Jessica M Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Stephen R Broderick
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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18
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Zhou AL, Ruck JM, Casillan AJ, Larson EL, Shou BL, Ha JS, Shah PD, Merlo CA, Bush EL. National utilization, trends, and lung transplant outcomes of static versus portable ex vivo lung perfusion platforms. J Thorac Cardiovasc Surg 2023:S0022-5223(23)01202-3. [PMID: 38141853 DOI: 10.1016/j.jtcvs.2023.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 11/20/2023] [Accepted: 12/16/2023] [Indexed: 12/25/2023]
Abstract
BACKGROUND This study compared utilization and outcomes of the 2 widely utilized ex vivo lung perfusion (EVLP) platforms in the United States: a static platform and a portable platform. METHODS Adult (age 18 years or older) bilateral lung-only transplants utilizing EVLP between February 28, 2018, and December 31, 2022, in the United Network for Organ Sharing database were included. Predischarge acute rejection, intubation at 72 hours posttransplant, extracorporeal membrane oxygenation at 72 hours posttransplant, primary graft dysfunction grade 3 at 72 hours posttransplant, 30-day mortality, and 1-year mortality were evaluated using multivariable regressions. RESULTS Overall, 607 (6.3%) lung transplants during the study period used EVLP (51.2% static, 48.8% portable). Static EVLP was primarily utilized in the eastern United States, whereas portable EVLP was primarily utilized in the western United States. Static EVLP donors were more likely to be donation after circulatory death (33.4% vs 26.0%; P = .005), have a >20 pack-year smoking history (13.5% vs 6.5%; P = .005), and be extended criteria donors (92.3% vs 85.0%; P = .013), whereas portable EVLP donors were more likely to be older than age 55 years (14.2% vs 8.0%; P = .02). Transplants utilizing the static and portable platforms had similar risk of acute rejection, intubation at 72 hours, extracorporeal membrane oxygenation at 72 hours, primary graft dysfunction grade 3 at 72 hours, and posttransplant mortality at 30 days and 1 year (all P values > .05). CONCLUSIONS The static and portable platforms had significant differences in donor characteristics and geographic distributions of utilization. Despite this, posttransplant survival was similar between the 2 EVLP platforms.
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Affiliation(s)
- Alice L Zhou
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md
| | - Jessica M Ruck
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md
| | - Alfred J Casillan
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md
| | - Emily L Larson
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md
| | - Benjamin L Shou
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md
| | - Jinny S Ha
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md
| | - Pali D Shah
- Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins Hospital, Baltimore, Md
| | - Christian A Merlo
- Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins Hospital, Baltimore, Md
| | - Errol L Bush
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md.
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19
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Zhou AL, Larson EL, Ruck JM, Ha JS, Casillan AJ, Bush EL. Current status and future potential of ex vivo lung perfusion in clinical lung transplantation. Artif Organs 2023; 47:1700-1709. [PMID: 37455548 DOI: 10.1111/aor.14607] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 05/29/2023] [Accepted: 06/19/2023] [Indexed: 07/18/2023]
Abstract
Lung transplantation is accepted as a well-established and effective treatment for patients with end-stage lung disease. While the number of candidates added to the waitlist continues to rise, the number of transplants performed remains limited by the number of suitable organ donors. Ex vivo lung perfusion (EVLP) emerged as a method of addressing the organ shortage by allowing the evaluation and potential reconditioning of marginal donor lungs or minimizing risks of prolonged ischemic time due to logistical challenges. The currently available FDA-approved EVLP systems have demonstrated excellent outcomes in clinical trials, and retrospective studies have demonstrated similar post-transplant survival between recipients who received marginal donor lungs perfused using EVLP and recipients who received standard criteria lungs stored using conventional methods. Despite this, widespread utilization has plateaued in the last few years, likely due to the significant costs associated with initiating EVLP programs. Centralized, dedicated EVLP perfusion centers are currently being investigated as a potential method of further expanding utilization of this technology. In the preclinical setting, potential applications of EVLP that are currently being studied include prolongation of organ preservation, reconditioning of unsuitable lungs, and further enhancement of already suitable lungs. As adoption of EVLP technology becomes more widespread, we may begin to see future implementation of these potential applications into the clinical setting.
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Affiliation(s)
- Alice L Zhou
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Emily L Larson
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Jessica M Ruck
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Jinny S Ha
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Alfred J Casillan
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Errol L Bush
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
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20
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T Jenkins R, M Shah M, L Larson E, L Zhou A, M Ruck J, Kilic A. Expanding the Criteria for Heart Transplantation Donors: A Review of DCD, Increased Ischemic Times, HCV, HIV, and Extended Criteria Donors. Heart Surg Forum 2023; 26:E639-E655. [PMID: 37920074 DOI: 10.59958/hsf.6677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 09/26/2023] [Indexed: 11/04/2023]
Abstract
With the demand for heart transplantation continuing to outpace the available donor organs, previously underutilized donors are now being reconsidered. We sought to describe the emerging techniques and outcomes of expanded criteria heart transplantation. A comprehensive review of the recent literature concerning expanded donor selection in heart transplantation was performed using the PubMed MEDLINE database. To characterize trends in transplant practice, the United Network for Organ Sharing (UNOS/OPTN) registry was queried for all adult isolated heart transplants since 2010, and data regarding transplant parameters was collected. Donation after cardiac death (DCD), DCD with normothermic regional perfusion, increased ischemic time, hepatitis C positive donor organs, HIV-positive donor organs, and extended criteria donors were identified as promising avenues currently being explored to expand the number of donor organs. The utilization of various expanded criteria for heart transplantation was summarized since 2010 and showed an increasing use of these donor organs, contributing to the overall increasing frequency of heart transplantation. Utilization of expanded criteria for donor selection in heart transplantation has the potential to increase the supply of donor organs with comparable outcomes in selected recipients.
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Affiliation(s)
- Reed T Jenkins
- Division of Cardiothoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD 21218, USA.
| | - Manuj M Shah
- Division of Cardiothoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD 21218, USA.
| | - Emily L Larson
- Division of Cardiothoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD 21218, USA.
| | - Alice L Zhou
- Division of Cardiothoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD 21218, USA.
| | - Jessica M Ruck
- Division of Cardiothoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD 21218, USA.
| | - Ahmet Kilic
- Division of Cardiothoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD 21218, USA.
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21
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Ruck JM, Bowring MG, Durand CM, Ha JS, Massie AB, Segev DL, Merlo CA, Bush EL. To decline or not to decline: Consequences of decision-making regarding lung offers from donors with hepatitis C. J Thorac Cardiovasc Surg 2023:S0022-5223(23)00757-2. [PMID: 37678605 PMCID: PMC10924072 DOI: 10.1016/j.jtcvs.2023.08.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 08/09/2023] [Accepted: 08/17/2023] [Indexed: 09/09/2023]
Abstract
OBJECTIVE Lung transplants from donors with hepatitis C (HCV D+) have excellent outcomes, but these organs continue to be declined. We evaluated whether (1) being listed to consider and (2) accepting versus declining HCV D+ offers provided a survival benefit to lung transplant candidates. METHODS Using the Scientific Registry of Transplant Recipients, we identified all adult (≥18 years) lung transplant candidates 2016-2021 and compared waitlist mortality between those willing versus not willing to consider HCV D+ offers using competing risk regression. We identified all candidates offered an HCV D+ lung that was later accepted and followed them from offer decision until death or end-of-study. We estimated adjusted mortality risk of accepting versus declining an HCV D+ lung offer using propensity-weighted Cox regression. RESULTS From 2016 to 2021, we identified 21,007 lung transplant candidates, 33.8% of whom were willing to consider HCV D+ offers. Candidates willing to consider HCV D+ offers had a 17% lower risk of waitlist mortality (subhazard ratio, 0.83; 95% confidence interval, 0.75-0.91, P < .001). Over the same period, 665 HCV D+ lung offers were accepted after being declined a total of 2562 times. HCV D+ offer acceptance versus decline was associated with a 20% lower risk of mortality (adjusted hazard ratio, 0.80; 95% confidence interval, 0.66-0.96, P = .02). CONCLUSIONS Considering HCV D+ lung offers was associated with a 17% lower risk of waitlist mortality, whereas accepting versus declining an HCV D+ lung offer was associated with a 20% lower risk of mortality. Centers and candidates should consider accepting suitable HCV D+ lung offers to optimize outcomes.
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Affiliation(s)
- Jessica M Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Mary G Bowring
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Christine M Durand
- Division of Infectious Disease, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Jinny S Ha
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Allan B Massie
- Department of Surgery, New York University Grossman School of Medicine and Langone Health, New York, NY; Department of Population Health, New York University Grossman School of Medicine and Langone Health, New York, NY
| | - Dorry L Segev
- Department of Surgery, New York University Grossman School of Medicine and Langone Health, New York, NY; Department of Population Health, New York University Grossman School of Medicine and Langone Health, New York, NY; Scientific Registry of Transplant Recipients, Minneapolis, Minn
| | - Christian A Merlo
- Division of Pulmonology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Errol L Bush
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md.
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22
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Bowring MG, Ruck JM, Bryski MG, Werbel W, Tobian AAR, Massie AB, Segev DL, Durand CM. Impact of expanding HOPE Act experience criteria on program eligibility for transplantation from donors with human immunodeficiency virus to recipients with human immunodeficiency virus. Am J Transplant 2023; 23:860-864. [PMID: 36907248 PMCID: PMC10247519 DOI: 10.1016/j.ajt.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 02/13/2023] [Accepted: 03/06/2023] [Indexed: 03/13/2023]
Affiliation(s)
- Mary G Bowring
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jessica M Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Mitchell G Bryski
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - William Werbel
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Aaron A R Tobian
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Allan B Massie
- Department of Surgery, NYU Langone Transplant Institute, NYU Langone Health, New York, New York, USA
| | - Dorry L Segev
- Department of Surgery, NYU Langone Transplant Institute, NYU Langone Health, New York, New York, USA; Division of Special Studies, Scientific Registry of Transplant Recipients, Minneapolis, Minnesota, USA
| | - Christine M Durand
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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23
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Ruck JM, Zeiser LB, Zhou AL, Chidi AP, Winchester SL, Durand CM, Ha JS, Shah PD, Massie AB, Segev DL, Merlo CA, Bush EL. Trends in use and three-year outcomes of hepatitis C virus-viremic donor lung transplants for hepatitis C virus-seronegative recipients. J Thorac Cardiovasc Surg 2023; 165:1587-1595.e2. [PMID: 36207160 PMCID: PMC9989038 DOI: 10.1016/j.jtcvs.2022.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Received: 05/01/2022] [Revised: 08/18/2022] [Accepted: 08/18/2022] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The feasibility and 6-month outcome safety of lung transplants (LTs) from hepatitis C virus (HCV)-viremic donors for HCV-seronegative recipients (R-) were established in 2019, but longer-term safety and uptake of this practice nationally remain unknown. METHODS We identified HCV-seronegative LT recipients (R-) 2015-2020 using the Scientific Registry of Transplant Recipients. We classified donors as seronegative (D-) or viremic (D+). We used χ2 testing, rank-sum testing, and Cox regression to compare posttransplant outcomes between HCV D+/R- and D-/R- LT recipients. RESULTS HCV D+/R- LT increased from 2 to 97/year; centers performing HCV D+/R- LT increased from 1 to 25. HCV D+/R- versus HCV D-/R- LT recipients had more obstructive disease (35.7% vs 23.3%, P < .001), lower lung allocation score (36.5 vs 41.1, P < .001), and longer waitlist time (P = .002). HCV D+/R- LT had similar risk of acute rejection (adjusted odds ratio [aOR], 0.87; P = .58), extracorporeal membranous oxygenation (aOR, 1.94; P = .10), and tracheostomy (aOR, 0.42; P = .16); similar median hospital stay (P = .07); and lower risk of ventilator > 48 hours (aOR, 0.68; P = .006). Adjusting for donor, recipient, and transplant characteristics, risk of all-cause graft failure and mortality were similar at 30 days, 1 year, and 3 years for HCV D+/R- versus HCV D-/R- LT (all P > .1), as well as for high- (≥20/year) versus low-volume LT centers and high- (≥5/year) versus low-volume HCV D+/R- LT centers (all P > .5). CONCLUSIONS HCV D+/R- and HCV D-/R- LT have similar outcomes at 3 years posttransplant. These results underscore the safety of HCV D+/R- LT and the potential benefit of expanding this practice further.
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Affiliation(s)
- Jessica M Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Laura B Zeiser
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Alice L Zhou
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Alexis P Chidi
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | | | - Christine M Durand
- Division of Infectious Disease, Deparment of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Jinny S Ha
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Pali D Shah
- Division of Pulmonology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Allan B Massie
- Department of Surgery, NYU Langone School of Medicine, New York, NY
| | - Dorry L Segev
- Department of Surgery, NYU Langone School of Medicine, New York, NY; Scientific Registry of Transplant Recipients, Minneapolis, Minn
| | - Christian A Merlo
- Division of Pulmonology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Errol L Bush
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md.
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24
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Bendersky VA, Saha A, Sidoti CN, Ferzola A, Downey M, Ruck JM, Vanterpool KB, Young L, Shegelman A, Segev DL, Levan ML. Factors impacting the medication "Adherence Landscape" for transplant patients. Clin Transplant 2023:e14962. [PMID: 36950850 DOI: 10.1111/ctr.14962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 02/16/2023] [Accepted: 02/27/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND Medication non-adherence contributes to post-transplant graft rejection and failure; however, limited knowledge about the reasons for non-adherence hinders the development of interventions to improve adherence. We conducted focus groups with solid organ transplant recipients regarding overlooked challenges in the process of transplant medication self-management and examined their adherence strategies and perceptions towards the post-transplant medication regimen. METHODS We conducted four focus groups with n = 31 total adult transplant recipients. Participants had received kidney, liver, or combined liver/kidney transplant at Johns Hopkins Hospital between 2014 and 2019. Focus groups were audio-recorded and transcribed. Transcripts were analyzed inductively, using the constant comparative method. RESULTS Responses generally fell into two major categories: (1) barriers to adherence and (2) "adherence landscape". We define the former as factors directly labeled as barriers to adherence by participants and the latter as factors that heavily influence the post-transplant medication self-management process. CONCLUSIONS We propose a shift in the way healthcare providers and researchers, address the question of medication non-adherence. Rather than asking why patients are non-adherent, we suggest that constructing and understanding patients' "adherence landscape" will provide an optimal way to align the goals of patients and providers and boost health outcomes.
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Affiliation(s)
- Victoria A Bendersky
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Amrita Saha
- Rotman School of Management, University of Toronto, Ontario, Canada
| | - Carolyn N Sidoti
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA
| | - Alexander Ferzola
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Max Downey
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA
| | - Jessica M Ruck
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Karen B Vanterpool
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA
| | - Lisa Young
- Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Abigail Shegelman
- Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, USA
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA
- Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Macey L Levan
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Department of Surgery, New York University Grossman School of Medicine, New York, New York, USA
- Department of Population Health, New York University Grossman School of Medicine, New York, New York, USA
- Department of Acute and Chronic Care, Johns Hopkins School of Nursing, Baltimore, Maryland, USA
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25
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Ruck JM, King EA, Chu NM, Segev DL, McAdams-DeMarco M. Delirium in Liver Transplantation. Curr Transpl Rep 2023. [DOI: 10.1007/s40472-023-00391-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
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26
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Ruck JM, King EA, Chu NM, Segev DL, McAdams-DeMarco M. Cognitive Dysfunction in Liver Disease and Its Implications for Transplant Candidates. Curr Transpl Rep 2023. [DOI: 10.1007/s40472-023-00390-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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27
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Ruck JM, Zhou AL, Zeiser LB, Alejo D, Durand CM, Massie AB, Segev DL, Bush EL, Kilic A. Trends and three-year outcomes of hepatitis C virus-viremic donor heart transplant for hepatitis C virus-seronegative recipients. JTCVS Open 2022; 12:269-279. [PMID: 36590744 PMCID: PMC9801334 DOI: 10.1016/j.xjon.2022.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 10/17/2022] [Accepted: 10/24/2022] [Indexed: 11/06/2022]
Abstract
Objective Heart transplants (HTs) from hepatitis C virus (HCV)-viremic donors to HCV-seronegative recipients (HCV D+/R-) have good 6-month outcomes, but practice uptake and long-term outcomes overall and among candidates on mechanical circulatory support (MCS) have yet to be established. Methods Using the Scientific Registry of Transplant Recipients, we identified US adult HCV-seronegative HT recipients (R-) from 2015 to 2021. We classified donors as HCV-seronegative (D-) or HCV-viremic (D+). We used multivariable regression to compare post-HT extracorporeal membranous oxygenation, dialysis, pacemaker, acute rejection, and risk of post-HT mortality between HCV D+/R- and HCV D-/R-. Models were adjusted for donor, recipient, and transplant characteristics and center HT volume. We performed subgroup analyses of recipients bridged with MCS. Results From 2015 to 2021, the number of HCV D+/R- HT increased from 1 to 181 and the number of centers performing HCV D+/R- HT increased from 1 to 60. Compared with HCV D-/R- recipients, HCV D+/R- versus D-/R- recipients overall and among patients bridged with MCS had similar odds of post-HT extracorporeal membranous oxygenation, dialysis, pacemaker, and acute rejection; and mortality risk at 30 days, 1 year, and 3 years (all P > .05). High center HT volume but not HCV D+/R- volume (<5 vs >5 in any year) was associated with lower mortality for HCV D+/R- HT. Conclusions HCV D+/R- and D-/R- HT have similar outcomes at 3 years' posttransplant. These results underscore the opportunity provided by HCV D+/R- HT, including among the growing population bridged with MCS, and the potential benefit of further expanding use of HCV+ allografts.
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Key Words
- D+, HCV-viremic donor
- DAAs, direct-acting antivirals
- DCD, donation after circulatory death
- D–, HCV-seronegative donor
- ECMO, extracorporeal membranous oxygenation
- HCV, hepatitis C virus
- HT, heart transplant
- IABP, intra-aortic balloon pump
- IQR, interquartile range
- LVAD, left ventricular assist device
- MCS, mechanical circulatory support
- R–, HCV-seronegative recipient
- SRTR, Scientific Registry of Transplant Recipients
- aHR, adjusted hazard ratio
- aOR, adjusted odds ratio
- donor pool
- heart transplant
- hepatitis C
- outcomes
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Affiliation(s)
- Jessica M. Ruck
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Alice L. Zhou
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Laura B. Zeiser
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Diane Alejo
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Christine M. Durand
- Division of Infection Disease, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Allan B. Massie
- Division of Transplant Surgery, Department of Surgery, NYU Langone Health, New York, NY
| | - Dorry L. Segev
- Division of Transplant Surgery, Department of Surgery, NYU Langone Health, New York, NY,Scientific Registry of Transplant Recipients, Minneapolis, Minn
| | - Errol L. Bush
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Ahmet Kilic
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md,Address for reprints: Ahmet Kilic, MD, Department of Surgery, Johns Hopkins Medical Institutions, Sheikh Zayed Tower, Suite 7107, 1800 Orleans St, Baltimore, MD 21287.
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28
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Alejo JL, Ruck JM, Chiang TPY, Abedon AT, Kim JD, Avery RK, Tobian AAR, Warren DS, Levan ML, Massie AB, Garonzik‐Wang JM, Segev DL, Werbel WA. Antibody response to a third dose of SARS-CoV-2 vaccine in heart and lung transplant recipients. Clin Transplant 2022; 36:e14818. [PMID: 36073912 PMCID: PMC9538949 DOI: 10.1111/ctr.14818] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 08/17/2022] [Accepted: 09/05/2022] [Indexed: 12/15/2022]
Affiliation(s)
- Jennifer L. Alejo
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Jessica M. Ruck
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Teresa P. Y. Chiang
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Aura T. Abedon
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Jake D. Kim
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Robin K. Avery
- Department of PathologyJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Aaron A. R. Tobian
- Department of PathologyJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Daniel S. Warren
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Macey L. Levan
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMarylandUSA
- Department of SurgeryNYU Grossman School of MedicineNew YorkNew YorkUSA
| | - Allan B. Massie
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMarylandUSA
- Department of SurgeryNYU Grossman School of MedicineNew YorkNew YorkUSA
| | | | - Dorry L. Segev
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMarylandUSA
- Department of SurgeryNYU Grossman School of MedicineNew YorkNew YorkUSA
| | - William A. Werbel
- Department of MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
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29
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Frey S, Ruck JM, Alejo JL, Barker L, Matthew J, Werbel WA, Avery RK, Segev DL, Shah PD. Perivaccination Antimetabolite Hold and Third Dose of SARS-CoV-2 Vaccine in Lung Transplant Recipients: Preliminary Report. Transplantation 2022; 106:e426-e428. [PMID: 35698264 PMCID: PMC10123514 DOI: 10.1097/tp.0000000000004240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Sarah Frey
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jessica M. Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jennifer L. Alejo
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Lindsay Barker
- Division of Pulmonology and Critical Care, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Joby Matthew
- Division of Pulmonology and Critical Care, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Robin K. Avery
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Surgery, New York University, New York, NY
| | - Pali D. Shah
- Division of Pulmonology and Critical Care, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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30
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Ruck JM, Jackson KR, Motter JD, Massie AB, Philosophe B, Cameron AM, Ottmann SE, Wesson R, Gurakar AO, Segev DL, Garonzik-Wang J. Temporal Trends in Utilization and Outcomes of DCD Livers in the United States. Transplantation 2022; 106:543-551. [PMID: 34259435 DOI: 10.1097/tp.0000000000003878] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Historically, donation after circulatory death (DCD) livers were frequently discarded because of higher mortality and graft loss after liver transplantation (LT). However, the demand for LT continues to outstrip the supply of "acceptable" organs. Additionally, changes in the donor pool, organ allocation, and clinical management of donors and recipients, and improved clinical protocols might have altered post-DCD-LT outcomes. METHODS We studied 5975 recovered DCD livers using US Scientific Registry of Transplant Recipients data from 2005 to 2017, with a comparison group of 78 235 adult donation after brain death (DBD) livers recovered during the same time period. We quantified temporal trends in discard using adjusted multilevel logistic regression and temporal trends in post-LT mortality and graft loss for DCD LT recipients using adjusted Cox regression. RESULTS DCD livers were more likely to be discarded than DBD livers across the entire study period, and the relative likelihood of discard increased over time (adjusted odds ratio [aOR] of discard DCD versus DBD 3.854.455.14 2005-2007, 5.225.876.59 2015-2017) despite improving outcomes after DCD LT. Mortality risk for DCD LTs decreased in each time period (compared with 2005-2007, aHR 2008-2011 0.720.840.97, aHR 2012-2014 0.480.580.70, aHR 2015-2017 0.340.430.55), as did risk of graft loss (compared with 2005-2007, aHR 2008-2011 0.690.810.94, aHR 2012-2014 0.450.550.67, aHR 2015-2017 0.360.450.56). CONCLUSIONS Despite dramatic improvements in outcomes of DCD LT recipients, DCD livers remain substantially more likely to be discarded than DBD livers, and this discrepancy has actually increased over time. DCD livers are underutilized and have the potential to expand the donor pool.
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Affiliation(s)
- Jessica M Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kyle R Jackson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jennifer D Motter
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Allan B Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Benjamin Philosophe
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Andrew M Cameron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Shane E Ottmann
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Russell Wesson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ahmet O Gurakar
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.,Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD.,Scientific Registry of Transplant Recipients, Minneapolis, MN
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31
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Sheng JY, Skuli SJ, Thorner ED, Zafman N, Riley CD, Ruck JM, Smith KC, Snyder C, Smith KL, Stearns V, Wolff AC. Late effects in a high-risk population of breast cancer survivors. Support Care Cancer 2022; 30:1749-1757. [PMID: 34586509 PMCID: PMC8732297 DOI: 10.1007/s00520-021-06597-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 09/26/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE To better understand the impact of cancer and treatment on outcomes and guide program development, we evaluated breast cancer survivors at risk for long-term medical and psychosocial issues who participated in survivorship care visits (SVs) at Johns Hopkins Hospital. METHODS We conducted a prospective survey study of women with stage I-III breast cancer who participated in SVs from 2010-2016. The same 56-item questionnaire administered at SV and follow-up included an assessment of symptoms, social factors, demographics, anxiety, depression, and comorbidities. We added the Godin Exercise questionnaire to the follow-up. RESULTS In 2018, 74 participants were identified as disease-free and mailed a follow-up survey; 52 (70.3%) completed the survey. At a median follow-up time of 3.1 years after diagnosis, participants were less likely to be employed (54% vs. 67%) than at the SV. About two-thirds were sedentary, and this was associated with high body mass index (p = 0.02). Sufficiently active participants (≥ 150 min per week of moderate-intensity activity) were less likely to report pain (p = 0.02) or fatigue (p = 0.001). Although 19% had moderate/severe anxiety or depression at follow-up, participants who reported employment satisfaction were less likely to be depressed (p = 0.02). CONCLUSIONS Awareness of issues faced by survivors is critical for enhancing care and developing models to identify patients who might benefit most from targeted long-term interventions. IMPLICATIONS FOR CANCER SURVIVORS Interventions to address physical activity, persistent symptoms, and mental health are critical for breast cancer survivors.
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Affiliation(s)
- Jennifer Y Sheng
- School of Medicine, The Johns Hopkins University, Baltimore, MD, USA.
- Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University, Baltimore, MD, USA.
| | - Sarah J Skuli
- Department of Medicine, The Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Elissa D Thorner
- Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University, Baltimore, MD, USA
| | - Nelli Zafman
- Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University, Baltimore, MD, USA
| | - Carol D Riley
- Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University, Baltimore, MD, USA
| | - Jessica M Ruck
- School of Medicine, The Johns Hopkins University, Baltimore, MD, USA
| | - Katherine C Smith
- Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University, Baltimore, MD, USA
- The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Claire Snyder
- School of Medicine, The Johns Hopkins University, Baltimore, MD, USA
- Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University, Baltimore, MD, USA
- The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Karen L Smith
- School of Medicine, The Johns Hopkins University, Baltimore, MD, USA
- Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University, Baltimore, MD, USA
| | - Vered Stearns
- School of Medicine, The Johns Hopkins University, Baltimore, MD, USA
- Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University, Baltimore, MD, USA
| | - Antonio C Wolff
- School of Medicine, The Johns Hopkins University, Baltimore, MD, USA
- Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University, Baltimore, MD, USA
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32
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Boyarsky BJ, Ruck JM, Chiang TPY, Werbel WA, Strauss AT, Getsin SN, Jackson KR, Kernodle AB, Van Pilsum Rasmussen SE, Baker TB, Al Ammary F, Durand CM, Avery RK, Massie AB, Segev DL, Garonzik-Wang JM. Evolving Impact of COVID-19 on Transplant Center Practices and Policies in the United States. Clin Transplant 2020; 34:e14086. [PMID: 32918766 DOI: 10.1111/ctr.14086] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [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: 07/02/2020] [Revised: 08/26/2020] [Accepted: 09/04/2020] [Indexed: 12/20/2022]
Abstract
In our first survey of transplant centers in March 2020, >75% of kidney and liver programs were either suspended or operating under restrictions. To safely resume transplantation, we must understand the evolving impact of COVID-19 on transplant recipients and center-level practices. We therefore conducted a six-week follow-up survey May 7-15, 2020, and linked responses to the COVID-19 incidence map, with a response rate of 84%. Suspension of live donor transplantation decreased from 72% in March to 30% in May for kidneys and from 68% to 52% for livers. Restrictions/suspension of deceased donor transplantation decreased from 84% to 58% for kidneys and from 73% to 42% for livers. Resuming transplantation at normal capacity was envisioned by 83% of programs by August 2020. Exclusively using local recovery teams for deceased donor procurement was reported by 28%. Respondents reported caring for a total of 1166 COVID-19-positive transplant recipients; 25% were critically ill. Telemedicine challenges were reported by 81%. There was a lack of consensus regarding management of potential living donors or candidates with SARS-CoV-2. Our findings demonstrate persistent heterogeneity in center-level response to COVID-19 even as transplant activity resumes, making ongoing national data collection and real-time analysis critical to inform best practices.
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Affiliation(s)
- Brian J Boyarsky
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jessica M Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Teresa Po-Yu Chiang
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - William A Werbel
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alexandra T Strauss
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Samantha N Getsin
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kyle R Jackson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amber B Kernodle
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Talia B Baker
- Department of Surgery, University of Chicago School of Medicine, Chicago, IL, USA
| | - Fawaz Al Ammary
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christine M Durand
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Robin K Avery
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Allan B Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
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33
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Thomas AG, Ruck JM, Chu NM, Agoons D, Shaffer AA, Haugen CE, Swenor B, Norman SP, Garonzik-Wang J, Segev DL, McAdams-DeMarco M. Kidney transplant outcomes in recipients with visual, hearing, physical and walking impairments: a prospective cohort study. Nephrol Dial Transplant 2020; 35:1262-1270. [PMID: 31411724 PMCID: PMC7417011 DOI: 10.1093/ndt/gfz164] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 07/04/2019] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Disability in general has been associated with poor outcomes in kidney transplant (KT) recipients. However, disability can be derived from various components, specifically visual, hearing, physical and walking impairments. Different impairments may compromise the patient through different mechanisms and might impact different aspects of KT outcomes. METHODS In our prospective cohort study (June 2013-June 2017), 465 recipients reported hearing, visual, physical and walking impairments before KT. We used hybrid registry-augmented Cox regression, adjusting for confounders using the US KT population (Scientific Registry of Transplant Recipients, N = 66 891), to assess the independent association between impairments and post-KT outcomes [death-censored graft failure (DCGF) and mortality]. RESULTS In our cohort of 465 recipients, 31.6% reported one or more impairments (hearing 9.3%, visual 16.6%, physical 9.1%, walking 12.1%). Visual impairment was associated with a 3.36-fold [95% confidence interval (CI) 1.17-9.65] higher DCGF risk, however, hearing [2.77 (95% CI 0.78-9.82)], physical [0.67 (95% CI 0.08-3.35)] and walking [0.50 (95% CI 0.06-3.89)] impairments were not. Walking impairment was associated with a 3.13-fold (95% CI 1.32-7.48) higher mortality risk, however, visual [1.20 (95% CI 0.48-2.98)], hearing [1.01 (95% CI 0.29-3.47)] and physical [1.16 (95% CI 0.34-3.94)] impairments were not. CONCLUSIONS Impairments are common among KT recipients, yet only visual impairment and walking impairment are associated with adverse post-KT outcomes. Referring nephrologists and KT centers should identify recipients with visual and walking impairments who might benefit from targeted interventions pre-KT, additional supportive care and close post-KT monitoring.
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Affiliation(s)
- Alvin G Thomas
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jessica M Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nadia M Chu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Dayawa Agoons
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ashton A Shaffer
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Christine E Haugen
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bonnielin Swenor
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Silas P Norman
- Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | | | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Mara McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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34
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Ruck JM, Jackson AM, Massie AB, Segev DL, Desai N, Garonzik-Wang J. Temporal Changes in the Impact of HLA Mismatching Among Pediatric Kidney Transplant Recipients. Transplantation 2020; 103:1267-1271. [PMID: 30130329 DOI: 10.1097/tp.0000000000002426] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Allocation for pediatric deceased-donor kidney transplantation (pDDKT) in the United States now de-emphasizes HLA matching to improve equality in access to transplantation, but other national systems still consider HLA matching due to concerns about graft survival. We hypothesized that the impact of HLA mismatching has decreased over time due to advances including improved immunosuppression. METHODS Using Scientific Registry of Transplant Recipient data, we analyzed whether the association between the number of HLA mismatches and outcomes of first-time pDDKTs changed between 2 eras: 1995 to 2004 (N = 2854) and 2005 to 2014 (N = 4643). RESULTS Between eras, the median number of mismatches increased from 4 to 5 (P < 0.001). Overall graft failure risk was higher among HLA-mismatched versus HLA-matched transplants (adjusted hazard ratio 1.211.431.69 for 3-6 versus 0-2 mismatches; P < 0.001), and this association was similar pre-2005 and post-2005 (Pinteraction = 0.5). Median panel-reactive antibody change at relisting increased from 79 to 85 (P = 0.01), but the association between number of HLA mismatches and panel-reactive antibody change was similar between eras (Pinteraction = 0.6). CONCLUSIONS Our finding that increased HLA mismatching continues to impact graft survival, with 43% higher risk of graft failure, highlights the tradeoff between transplant access equity and outcomes and calls into question the deemphasis on HLA matching in pDDKT allocation in the United States.
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Affiliation(s)
- Jessica M Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Annette M Jackson
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Allan B Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD.,Scientific Registry of Transplant Recipients, Minneapolis, MN
| | - Niraj Desai
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
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35
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Purnell TS, Luo X, Crews DC, Bae S, Ruck JM, Cooper LA, Grams ME, Henderson ML, Waldram MM, Johnson M, Segev DL. Neighborhood Poverty and Sex Differences in Live Donor Kidney Transplant Outcomes in the United States. Transplantation 2019; 103:2183-2189. [PMID: 30768570 DOI: 10.1097/tp.0000000000002654] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Neighborhood poverty has been associated with worse outcomes after live donor kidney transplantation (LDKT), and prior work suggests that women with kidney disease may be more susceptible to the negative influence of poverty than men. As such, our goal was to examine whether poverty differentially affects women in influencing LDKT outcomes. METHODS Using data from the Scientific Registry of Transplant Recipients and US Census, we performed multivariable Cox regression to compare outcomes among 18 955 women and 30 887 men who received a first LDKT in 2005-2014 with follow-up through December 31, 2016. RESULTS Women living in poor (adjusted hazard ratio [aHR], 1.30; 95% confidence interval [CI], 1.13-1.50) and middle-income (aHR, 1.26; 95% CI, 1.14-1.40) neighborhoods had higher risk of graft loss than men, but there were no differences in wealthy areas (aHR, 1.07; 95% CI, 0.88-1.29). Women living in wealthy (aHR, 0.71; 95% CI, 0.59-0.87) and middle-income (aHR, 0.82; 95% CI, 0.74-0.92) neighborhoods incurred a survival advantage over men, but there were no statistically significant differences in mortality in poor areas (aHR, 0.85; 95% CI, 0.72-1.01). CONCLUSIONS Given our findings that poverty is more strongly associated with graft loss in women, targeted efforts are needed to specifically address mechanisms driving these disparities in LDKT outcomes.
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Affiliation(s)
- Tanjala S Purnell
- Division of Transplantation, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Johns Hopkins Center for Health Equity, Johns Hopkins University, Baltimore, MD
| | - Xun Luo
- Division of Transplantation, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Deidra C Crews
- Johns Hopkins Center for Health Equity, Johns Hopkins University, Baltimore, MD
- Division of Nephrology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Sunjae Bae
- Division of Transplantation, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Jessica M Ruck
- Division of Transplantation, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Lisa A Cooper
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Johns Hopkins Center for Health Equity, Johns Hopkins University, Baltimore, MD
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Morgan E Grams
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Division of Nephrology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Macey L Henderson
- Division of Transplantation, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
- Johns Hopkins Center for Health Equity, Johns Hopkins University, Baltimore, MD
| | - Madeleine M Waldram
- Division of Transplantation, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
- Johns Hopkins Center for Health Equity, Johns Hopkins University, Baltimore, MD
| | - Morgan Johnson
- Division of Transplantation, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
- Johns Hopkins Center for Health Equity, Johns Hopkins University, Baltimore, MD
| | - Dorry L Segev
- Division of Transplantation, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Johns Hopkins Center for Health Equity, Johns Hopkins University, Baltimore, MD
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36
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Eno AK, Ruck JM, Van Pilsum Rasmussen SE, Waldram MM, Thomas AG, Purnell TS, Garonzik Wang JM, Massie AB, Al Almmary F, Cooper LM, Segev DL, Levan MA, Henderson ML. Perspectives on implementing mobile health technology for living kidney donor follow-up: In-depth interviews with transplant providers. Clin Transplant 2019; 33:e13637. [PMID: 31194892 PMCID: PMC6690770 DOI: 10.1111/ctr.13637] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 05/21/2019] [Accepted: 06/07/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND United States transplant centers are required to report follow-up data for living kidney donors for 2 years post-donation. However, living kidney donor (LKD) follow-up is often incomplete. Mobile health (mHealth) technologies could ease data collection burden but have not yet been explored in this context. METHODS We conducted semi-structured in-depth interviews with a convenience sample of 21 transplant providers and thought leaders about challenges in LKD follow-up, and the potential role of mHealth in overcoming these challenges. RESULTS Participants reported challenges conveying the importance of follow-up to LKDs, limited data from international/out-of-town LKDs, and inadequate staffing. They believed the 2-year requirement was insufficient, but expressed difficulty engaging LKDs for even this short time and inadequate resources for longer-term follow-up. Participants believed an mHealth system for post-donation follow-up could benefit LKDs (by simplifying communication/tasks and improving donor engagement) and transplant centers (by streamlining communication and decreasing workforce burden). Concerns included cost, learning curves, security/privacy, patient language/socioeconomic barriers, and older donor comfort with mHealth technology. CONCLUSIONS Transplant providers felt that mHealth technology could improve LKD follow-up and help centers meet reporting thresholds. However, designing a secure, easy to use, and cost-effective system remains challenging.
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Affiliation(s)
- Ann K Eno
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jessica M Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Madeleine M Waldram
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alvin G Thomas
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina
| | - Tanjala S Purnell
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland
- Department of Health Behavior and Society, Johns Hopkins School of Public Health, Baltimore, Maryland
- Johns Hopkins Center for Health Equity, Johns Hopkins University, Baltimore, Maryland
| | | | - Allan B Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Fawaz Al Almmary
- Division of Nephrology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Lisa M Cooper
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland
- Department of Health Behavior and Society, Johns Hopkins School of Public Health, Baltimore, Maryland
- Johns Hopkins Center for Health Equity, Johns Hopkins University, Baltimore, Maryland
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland
- Department of Acute and Chronic Care, Johns Hopkins School of Nursing, Baltimore, Maryland
| | | | - Macey L Henderson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Acute and Chronic Care, Johns Hopkins School of Nursing, Baltimore, Maryland
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37
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Thomas AG, Ruck JM, Shaffer AA, Haugen CE, Ying H, Warsame F, Chu N, Carlson MC, Gross AL, Norman SP, Segev DL, McAdams-DeMarco M. Kidney Transplant Outcomes in Recipients With Cognitive Impairment: A National Registry and Prospective Cohort Study. Transplantation 2019; 103:1504-1513. [PMID: 30153224 PMCID: PMC6393218 DOI: 10.1097/tp.0000000000002431] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Cognitive impairment is common in patients with end-stage renal disease and is associated with poor outcomes on dialysis. We hypothesized that cognitive impairment might be associated with an increased risk of all-cause graft loss (ACGL) in kidney transplant (KT) recipients. METHODS Using the Modified Mini-Mental State (3MS) examination, we measured global cognitive function at KT hospital admission in a prospective, 2-center cohort of 864 KT candidates (August 2009 to July 2016). We estimated the association between pre-KT cognitive impairment and ACGL using Cox regression, adjusting for recipient, donor, and transplant factors. RESULTS In living donor KT (LDKT) recipients, the prevalence was 3.3% for mild impairment (60 ≤ 3MS < 80) and 3.3% for severe impairment (3MS < 60). In deceased donor KT (DDKT) recipients, the prevalence was 9.8% for mild impairment and 2.6% for severe impairment. The LDKT recipients with cognitive impairment had substantially higher ACGL risk than unimpaired recipients (5-year ACGL: 45.5% vs 10.6%; P < 0.01; adjusted hazard ratio [aHR] any impairment, 5.40 (95% confidence interval [CI], 1.78-16.34; P < 0.01); aHR severe impairment, 5.57 (95% CI, 1.29-24.00; P = 0.02). Similarly, DDKT recipients with severe impairment had higher ACGL risk than recipients without severe impairment (5-year ACGL, 53.0% vs 24.2%; P = 0.04); aHR severe impairment, 2.92 (95% CI, 1.13-7.50; P = 0.03). CONCLUSIONS Given the elevated risk of ACGL among KT recipients with cognitive impairment observed in this 2-center cohort, research efforts should explore the mechanisms of graft loss and mortality associated with cognitive impairment and identify potential interventions to improve posttransplant survival.
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Affiliation(s)
- Alvin G. Thomas
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jessica M. Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ashton A. Shaffer
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Christine E. Haugen
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Hao Ying
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Fatima Warsame
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Nadia Chu
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Michelle C. Carlson
- Department of Mental Health, Johns Hopkins School of Public Health, Baltimore, MD
- Johns Hopkins University Center on Aging and Health, Baltimore, MD
| | - Alden L. Gross
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
- Johns Hopkins University Center on Aging and Health, Baltimore, MD
| | - Silas P. Norman
- Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, MI
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Mara McAdams-DeMarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
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38
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Henderson ML, Adler JT, Van Pilsum Rasmussen SE, Thomas AG, Herron PD, Waldram MM, Ruck JM, Purnell TS, DiBrito SR, Holscher CM, Haugen CE, Alimi Y, Konel JM, Eno AK, Garonzik Wang JM, Gordon EJ, Lentine KL, Schaffer RL, Cameron AM, Segev DL. How Should Social Media Be Used in Transplantation? A Survey of the American Society of Transplant Surgeons. Transplantation 2019; 103:573-580. [PMID: 29684002 PMCID: PMC6196114 DOI: 10.1097/tp.0000000000002243] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Social media platforms are increasingly used in surgery and have shown promise as effective tools to promote deceased donation and expand living donor transplantation. There is a growing need to understand how social media-driven communication is perceived by providers in the field of transplantation. METHODS We surveyed 299 members of the American Society of Transplant Surgeons about their use of, attitudes toward, and perceptions of social media and analyzed relationships between responses and participant characteristics. RESULTS Respondents used social media to communicate with: family and friends (76%), surgeons (59%), transplant professionals (57%), transplant recipients (21%), living donors (16%), and waitlisted candidates (15%). Most respondents (83%) reported using social media for at least 1 purpose. Although most (61%) supported sharing information with transplant recipients via social media, 42% believed it should not be used to facilitate living donor-recipient matching. Younger age (P = 0.02) and fewer years of experience in the field of transplantation (P = 0.03) were associated with stronger belief that social media can be influential in living organ donation. Respondents at transplant centers with higher reported use of social media had more favorable views about sharing information with transplant recipients (P < 0.01), increasing awareness about deceased organ donation (P < 0.01), and advertising for transplant centers (P < 0.01). Individual characteristics influence opinions about the role and clinical usefulness of social media. CONCLUSIONS Transplant center involvement and support for social media may influence clinician perceptions and practices. Increasing use of social media among transplant professionals may provide an opportunity to deliver high-quality information to patients.
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Affiliation(s)
- Macey L. Henderson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Acute and Chronic Care, Johns Hopkins University School of Nursing, Baltimore, MD
| | - Joel T. Adler
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | | | - Alvin G. Thomas
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Madeleine M. Waldram
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jessica M. Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Tanjala S. Purnell
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Sandra R. DiBrito
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Christine E. Haugen
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Yewande Alimi
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jonathan M. Konel
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ann K. Eno
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Elisa J. Gordon
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Krista L. Lentine
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, MO
| | | | - Andrew M. Cameron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
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Istl AC, Ruck JM, Morris CD, Levin AS, Meyer CF, Johnston FM. Call for improved design and reporting in soft tissue sarcoma studies: A systematic review and meta‐analysis of chemotherapy and survival outcomes in resectable STS. J Surg Oncol 2019; 119:824-835. [DOI: 10.1002/jso.25401] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 01/03/2019] [Accepted: 01/24/2019] [Indexed: 12/12/2022]
Affiliation(s)
- Alexandra C. Istl
- Division of General SurgeryWestern UniversityLondon ON Canada
- Johns Hopkins Bloomberg School of Public HealthBaltimore Maryland
| | - Jessica M. Ruck
- Department of SurgeryJohns Hopkins HospitalBaltimore Maryland
| | - Carol D. Morris
- Division of Orthopaedic OncologyJohns Hopkins HospitalBaltimore Maryland
| | - Adam S. Levin
- Division of Orthopaedic OncologyJohns Hopkins HospitalBaltimore Maryland
| | | | - Fabian M. Johnston
- Department of SurgeryJohns Hopkins HospitalBaltimore Maryland
- Division of Surgical OncologyJohns Hopkins HospitalBaltimore Maryland
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Garonzik-Wang JM, Lonze BE, Ruck JM, Luo X, Massie AB, Melancon K, Burdick JF, Segev DL, Sun Z. Mitochondrial membrane potential and delayed graft function following kidney transplantation. Am J Transplant 2019; 19:585-590. [PMID: 30408329 PMCID: PMC6349555 DOI: 10.1111/ajt.15174] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 10/21/2018] [Accepted: 10/21/2018] [Indexed: 01/25/2023]
Abstract
Delayed graft function (DGF) complicates 20%-40% of deceased-donor kidney transplants and is associated with increased length of stay and subsequent allograft failure. Accurate prediction of DGF risk for a particular allograft could influence organ allocation, patient counseling, and postoperative planning. Mitochondrial dysfunction, a reported surrogate of tissue health in ischemia-perfusion injury, might also be a surrogate for tissue health after organ transplantation. To understand the potential of mitochondrial membrane potential (MMP) in clinical decision-making, we analyzed whether lower MMP, a measure of mitochondrial dysfunction, was associated with DGF. In a prospective, single-center proof-of-concept study, we measured pretransplant MMP in 28 deceased donor kidneys and analyzed the association between MMP and DGF. We used hybrid registry-augmented regression to adjust for donor and recipient characteristics, minimizing overfitting by leveraging Scientific Registry of Transplant Recipients data. The range of MMP levels was 964-28 333 units. Low-MMP kidneys (MMP<4000) were more likely from female donors (75% vs 10%, P = .002) and donation after cardiac death donors (75% vs 12%, P = .004). For every 10% decrease in MMP levels, there were 38% higher odds of DGF (adjusted odds ratio = 1.08 1.381.78 , P = .01). In summary, MMP might be a promising pretransplant surrogate for tissue health in kidney transplantation and, after further validation, could improve clinical decision-making through its independent association with DGF.
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Affiliation(s)
| | - Bonnie E. Lonze
- Department of Surgery, NYU Langone Medical Center, New York, NY, USA
| | - Jessica M. Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Xun Luo
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Allan B. Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Keith Melancon
- George Washington University Hospital, Washington, DC, USA
| | - James F. Burdick
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Zhaoli Sun
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Ishaque T, Massie AB, Bowring MG, Haugen CE, Ruck JM, Halpern SE, Waldram MM, Henderson ML, Wang JG, Cameron AM, Philosophe B, Ottmann S, Rositch AF, Segev DL. Liver transplantation and waitlist mortality for HCC and non-HCC candidates following the 2015 HCC exception policy change. Am J Transplant 2019; 19:564-572. [PMID: 30312530 PMCID: PMC6349527 DOI: 10.1111/ajt.15144] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 09/24/2018] [Accepted: 10/02/2018] [Indexed: 01/25/2023]
Abstract
Historically, exception points for hepatocellular carcinoma (HCC) led to higher transplant rates and lower waitlist mortality for HCC candidates compared to non-HCC candidates. As of October 2015, HCC candidates must wait 6 months after initial application to obtain exception points; the impact of this policy remains unstudied. Using 2013-2017 SRTR data, we identified 39 350 adult, first-time, active waitlist candidates and compared deceased donor liver transplant (DDLT) rates and waitlist mortality/dropout for HCC versus non-HCC candidates before (October 8, 2013-October 7, 2015, prepolicy) and after (October 8, 2015-October 7, 2017, postpolicy) the policy change using Cox and competing risks regression, respectively. Compared to non-HCC candidates with the same calculated MELD, HCC candidates had a 3.6-fold higher rate of DDLT prepolicy (aHR = 3.49 3.69 3.89 ) and a 2.2-fold higher rate of DDLT postpolicy (aHR = 2.09 2.21 2.34 ). Compared to non-HCC candidates with the same allocation priority, HCC candidates had a 37% lower risk of waitlist mortality/dropout prepolicy (asHR = 0.54 0.63 0.73 ) and a comparable risk of mortality/dropout postpolicy (asHR = 0.81 0.95 1.11 ). Following the policy change, the DDLT advantage for HCC candidates remained, albeit dramatically attenuated, without any substantial increase in waitlist mortality/dropout. In the context of sickest-first liver allocation, the revised policy seems to have established allocation equity for HCC and non-HCC candidates.
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Affiliation(s)
- Tanveen Ishaque
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Allan B. Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Mary G. Bowring
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Christine E. Haugen
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jessica M. Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Samantha E. Halpern
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Madeleine M. Waldram
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Macey L. Henderson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | - Benjamin Philosophe
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Shane Ottmann
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Anne F. Rositch
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Ruck JM, Henderson ML, Eno AK, Van Pilsum Rasmussen SE, DiBrito SR, Thomas AG, Li R, Singer L, Massie I, Waldram MM, Konel JM, Helfer DR, Garonzik Wang JM, Purnell TS, Mogul DB, Lentine KL, Waterman AD, Segev DL. Use of Twitter in communicating living solid organ donation information to the public: An exploratory study of living donors and transplant professionals. Clin Transplant 2018; 33:e13447. [PMID: 30421841 DOI: 10.1111/ctr.13447] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [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: 05/08/2018] [Revised: 11/01/2018] [Accepted: 11/06/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND As transplant centers start leveraging Twitter for information dissemination and public engagement, it is important to understand current living solid organ donation-related Twitter use. METHODS We identified public Twitter profiles available in 01/2017 that referenced living organ donation and analyzed the use of donation-related Twitter handles, names, or profile information. Tweets were manually abstracted and qualitatively analyzed for common themes. Social media influence of those tweeting about living donation was evaluated using Klout score. RESULTS We identified 93 donors, 61 professionals, 12 hospitals, and 19 organizations that met eligibility criteria. Social media influence was similar across these groups (P = 0.4). Donors (16%) and organizations (23%) were more likely than professionals (7%) or hospitals (0%) to include transplant-related educational information in their profiles (P = 0.007). Living donation-related tweets were most commonly donation stories (33%), news reports (20%), reports about new transplant research (15%), and sharing transplant candidates' searches for donors (14%). CONCLUSIONS This exploratory study of living donors and transplant professionals, hospitals, and organizations on Twitter provides insight into how the social media platform may be used to communicate about and disseminate information about living donation.
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Affiliation(s)
- Jessica M Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Macey L Henderson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Acute and Chronic Care, Johns Hopkins School of Nursing, Baltimore, Maryland
| | - Ann K Eno
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Sandra R DiBrito
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alvin G Thomas
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rebecca Li
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lauren Singer
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Indraneel Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Madeleine M Waldram
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jonathan M Konel
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - David R Helfer
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Tanjala S Purnell
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Douglas B Mogul
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Krista L Lentine
- Center for Abdominal Transplantation, Saint Louis University, St. Louis, Missouri
| | - Amy D Waterman
- Department of Nephrology, University of California Los Angeles, Los Angeles, California
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Acute and Chronic Care, Johns Hopkins School of Nursing, Baltimore, Maryland.,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland
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Eno AK, Thomas AG, Ruck JM, Van Pilsum Rasmussen SE, Halpern SE, Waldram MM, Muzaale AD, Purnell TS, Massie AB, Garonzik Wang JM, Lentine KL, Segev DL, Henderson ML. Assessing the Attitudes and Perceptions Regarding the Use of Mobile Health Technologies for Living Kidney Donor Follow-Up: Survey Study. JMIR Mhealth Uhealth 2018; 6:e11192. [PMID: 30305260 PMCID: PMC6231841 DOI: 10.2196/11192] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [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: 05/31/2018] [Revised: 07/03/2018] [Accepted: 07/05/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND In 2013, the Organ Procurement and Transplantation Network began requiring transplant centers in the United States to collect and report postdonation living kidney donor follow-up data at 6 months, 1 year, and 2 years. Despite this requirement, <50% of transplant centers have been able to collect and report the required data. Previous work identified a number of barriers to living kidney donor follow-up, including logistical and administrative barriers for transplant centers and cost and functional barriers for donors. Novel smartphone-based mobile health (mHealth) technologies might reduce the burden of living kidney donor follow-up for centers and donors. However, the attitudes and perceptions toward the incorporation of mHealth into postdonation care among living kidney donors are unknown. Understanding donor attitudes and perceptions will be vital to the creation of a patient-oriented mHealth system to improve living donor follow-up in the United States. OBJECTIVE The goal of this study was to assess living kidney donor attitudes and perceptions associated with the use of mHealth for follow-up. METHODS We developed and administered a cross-sectional 14-question survey to 100 living kidney donors at our transplant center. All participants were part of an ongoing longitudinal study of long-term outcomes in living kidney donors. The survey included questions on smartphone use, current health maintenance behaviors, accessibility to health information, and attitudes toward using mHealth for living kidney donor follow-up. RESULTS Of the 100 participants surveyed, 94 owned a smartphone (35 Android, 58 iPhone, 1 Blackberry), 37 had accessed their electronic medical record on their smartphone, and 38 had tracked their exercise and physical activity on their smartphone. While 77% (72/93) of participants who owned a smartphone and had asked a medical question in the last year placed the most trust with their doctors, nurses, or other health care professionals regarding answering a health-related question, 52% (48/93) most often accessed health information elsewhere. Overall, 79% (74/94) of smartphone-owning participants perceived accessing living kidney donor information and resources on their smartphone as useful. Additionally, 80% (75/94) perceived completing some living kidney donor follow-up via mHealth as useful. There were no significant differences in median age (60 vs 59 years; P=.65), median years since donation (10 vs 12 years; P=.45), gender (36/75, 36%, vs 37/75, 37%, male; P=.57), or race (70/75, 93%, vs 18/19, 95%, white; P=.34) between those who perceived mHealth as useful for living kidney donor follow-up and those who did not, respectively. CONCLUSIONS Overall, smartphone ownership was high (94/100, 94.0%), and 79% (74/94) of surveyed smartphone-owning donors felt that it would be useful to complete their required follow-up with an mHealth tool, with no significant differences by age, sex, or race. These results suggest that patients would benefit from an mHealth tool to perform living donor follow-up.
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Affiliation(s)
- Ann K Eno
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Alvin G Thomas
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Department of Epidemiology, University of North Carolina, Chapel Hill, NC, United States
| | - Jessica M Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | | | - Samantha E Halpern
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Duke University School of Medicine, Durham, NC, United States
| | - Madeleine M Waldram
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Abimereki D Muzaale
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Tanjala S Purnell
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, United States.,Department of Health, Behavior, and Society, Johns Hopkins School of Public Health, Baltimore, MD, United States
| | - Allan B Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, United States
| | | | - Krista L Lentine
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, MO, United States
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, United States.,Department of Acute and Chronic Care, Johns Hopkins School of Nursing, Baltimore, MD, United States
| | - Macey L Henderson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Department of Acute and Chronic Care, Johns Hopkins School of Nursing, Baltimore, MD, United States
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Werner JD, Frangakis C, Ruck JM, Hong K, Philosophe B, Cameron AM, Saberi B, Gurakar A, Georgiades C. Neoadjuvant Transarterial Chemoembolization Improves Survival After Liver Transplant in Patients With Hepatocellular Carcinoma. EXP CLIN TRANSPLANT 2018; 17:638-643. [PMID: 30251938 DOI: 10.6002/ect.2018.0017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Our aims were to determine whether transarterial chemoembolization before liver transplant for hepatocellular carcinoma improves posttransplant survival and whether patients downstaged by transarterial chemoembolization within Milan criteria have a posttransplant survival benefit. MATERIALS AND METHODS In this retrospective analysis of prospectively collected data, survival rates of 87 patients treated with and 68 patients not treated with transarterial chemoembolization before liver transplant were compared using 2-sample t tests and multivariate Cox regression. We also compared posttransplant survival of patients within Milan criteria versus those downstaged after transarterial chemoembolization. We controlled for disease severity by assessing, among other variables, tumor diameter before and at transplant and alpha-fetoprotein levels before transplant and transarterial chemoembolization. RESULTS Overall 1-, 3-, and 5-year survival rates were 84%, 71%, and 63%, respectively. These rates were 91%, 78%, and 73% for patients who received and 76%, 63%, and 54% for patients who did not receive transarterial chemoembolization. Hazard ratios were 0.56 for having versus not having transarterial chemoembolization (P = .04), 1.06 for total tumor diameter on explantation (P = .01), 1.5 for largest tumor > 3 cm (P = .15), and 2.9 for pretransplant alpha-fetoprotein > 659 ng/mL (P = .006). A higher end-stage liver disease score correlated with poorer overall survival (hazard ratio = 1.53; P < .001). Laboratory values, lipiodol uptake, imaging response, and downstaging into Milan criteria were not correlated with survival. CONCLUSIONS Patients with hepatocellular carcinoma who were treated with neoadjuvant transarterial chemoembolization had better survival rates posttransplant than those not treated with transarterial chemoembolization. A high pretransplant alpha-fetoprotein level was negatively correlated with survival. Patients downstaged to Milan criteria after transarterial chemoembolization fared equally well versus those who met Milan criteria initially. Pretreatment with transarterial chemoembolization was positively correlated with survival posttransplant, with patients having a 44% reduction in posttransplant mortality.
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Affiliation(s)
- John D Werner
- From the Division of Vascular and Interventional Radiology, Department of Radiology, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
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Abstract
BACKGROUND Although mounting evidence supports the use of palliative care (PC) to improve care experiences and quality of life for oncology patients, the frequency of and factors associated with PC use during oncology-related hospitalizations remain unknown. MATERIALS AND METHODS Using the National Inpatient Sample dataset, hospitalizations during 2012-2014 for a primary diagnosis of cancer with high risk of in-hospital mortality were identified. PC use was identified using the V66.7 ICD-9 code. Factors associated with the cost of hospitalization were identified using multivariable gamma regression. RESULTS During the study period, 124,186 hospitalizations were identified with a primary diagnosis of malignancy (melanoma, breast, colon, gynecologic, prostate, male genitourinary, head/neck, urinary tract, noncolon gastrointestinal, lung, brain, bone/soft tissue, endocrine, or nonlung thoracic). Most patients were treated at a teaching hospital (51-77% by cancer type), and use of PC ranged from 10% for patients with endocrine cancers to 31% for patients with melanoma. Patients utilizing PC had a lower frequency of operative procedures (4-33% vs. 34-79% by cancer type, all p ≤ 0.001), a higher rate of in-hospital death (30-45% vs. 4-10% by cancer type, all p < 0.001), and a lower total hospitalization cost (median: $5076-17,151 vs. $10,918-29,287 by cancer type, p ≤ 0.01 except male genitourinary). In an adjusted analysis, the cost of hospitalization was significantly associated (all p < 0.001) with patient gender, race, age, operative, in-hospital death, extended length of stay, and PC. CONCLUSIONS In summary, inpatient PC utilization varied by cancer type. PC was associated with lower utilization of surgical procedures, shorter length of stay, and lower hospitalization cost. Lower hospitalization cost was also seen for patients who were older, female, or African American.
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Affiliation(s)
- Jessica M. Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joseph K. Canner
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Thomas J. Smith
- Palliative Care Program, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Hospital, Baltimore, Maryland
| | - Fabian M. Johnston
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Ruck JM, Van Pilsum Rasmussen SE, Henderson ML, Massie AB, Segev DL. Interviews of living kidney donors to assess donation-related concerns and information-gathering practices. BMC Nephrol 2018; 19:130. [PMID: 29884126 PMCID: PMC5994029 DOI: 10.1186/s12882-018-0935-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 05/29/2018] [Indexed: 11/18/2022] Open
Abstract
Background Efforts are underway to improve living kidney donor (LKD) education, but current LKD concerns and information-gathering preferences have not been ascertained to inform evidence-based resource development. As a result, prior studies have found that donors desire information that is not included in current informed consent and/or educational materials. Methods We conducted semi-structured interviews with 50 LKDs who donated at our center to assess (1) concerns about donation that they either had personally before or after donation or heard from family members or friends, (2) information that they had desired before donation, and (3) where they sought information about donation. We used thematic analysis of verbatim interview transcriptions to identify donation-related concerns. We compared the demographic characteristics of participants reporting specific concerns using Fisher’s exact test. Results We identified 19 unique concerns that participants had or heard about living kidney donation. 20% of participants reported having had no pre-donation concerns; 38% reported no post-donation concerns. The most common concern pre-donation was future kidney failure (22%), post-donation was the recovery process (24%), and from family was endangering their family unit (16%). 44% of participants reported being less concerned than family. 26% of participants wished they had had additional information prior to donating, including practical advice for recovery (10%) and information about specific complications (14%). Caucasian participants were more likely to hear at least one concern from family (76% vs. 33%, p = 0.02). The most commonly consulted educational resources were health care providers (100%) and websites (79% of donors since 2000). 26% of participants had had contact with other donors; an additional 20% desired contact with other LKDs. Conclusions Potential donors not only have personal donation-related concerns but frequently hear donation-related concerns from family members and friends. Current gaps in donor education include an absence of practical, peer-to-peer advice about donation from other prior donors and materials directed and potential donors’ family members and friends. These findings can inform the development of new educational practices and resources targeted not only at LKDs but at their social networks.
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Affiliation(s)
- Jessica M Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, 720 Rutland Ave, Ross 34, Baltimore, MD, 21205, USA.
| | - Sarah E Van Pilsum Rasmussen
- Department of Surgery, Johns Hopkins University School of Medicine, 720 Rutland Ave, Ross 34, Baltimore, MD, 21205, USA
| | - Macey L Henderson
- Department of Surgery, Johns Hopkins University School of Medicine, 720 Rutland Ave, Ross 34, Baltimore, MD, 21205, USA
| | - Allan B Massie
- Department of Surgery, Johns Hopkins University School of Medicine, 720 Rutland Ave, Ross 34, Baltimore, MD, 21205, USA.,Department of Epidemiology, Johns Hopkins School of Public Health, 720 Rutland Ave, Ross 34, Baltimore, MD, 21205, USA
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, 720 Rutland Ave, Ross 34, Baltimore, MD, 21205, USA.,Department of Epidemiology, Johns Hopkins School of Public Health, 720 Rutland Ave, Ross 34, Baltimore, MD, 21205, USA
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Chalouhy C, Ruck JM, Zhou T, Sirvastava A, Keehn A, Watts K, Maria P, Ghavamian R. Robotic Partial Nephrectomy in Patients with Chronic Kidney Disease: Objective Measurement of Short- and Long-Term Renal Functional Outcomes. J Endourol 2018; 32:630-634. [PMID: 29848053 DOI: 10.1089/end.2018.0151] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Minimal literature informs the use of robotic partial nephrectomy (RPN) in patients with chronic kidney disease (CKD). Therefore, we evaluated the renal functional outcomes in CKD patients undergoing RPN. METHODS We reviewed a prospective database of patients undergoing RPN 2010 to 2015 and identified 182 patients who had preoperative and postoperative nuclear renal scintigraphy (at 2 and 12 months postop). Preoperative and 12-month postoperative eGFR (mL/min/1.73 m2, by MDRD) were calculated. CKD was defined as eGFR ≤60 mL/min/1.73 m2 (CKD stages III and IV). Changes in creatinine, eGFR, and split function on mercaptoacetyltriglycine (MAG)-3 scan were compared by baseline CKD status. Correlations between pre- and postoperative eGFR were calculated. RESULTS Of 182 patients, 30 (16.5%) had baseline CKD. Preoperative eGFR was 48.5 and 99.0 in CKD and non-CKD patients, respectively (p < 0.001). From preoperation to 12 months postoperation, eGFR decreased by 2.8 and 1.1 mL/min/1.73 m2, respectively (p = 0.6). On MAG-3 scan, the contribution of the surgical kidney to overall renal function decreased by 5.0% and 4.8% (p = 0.9) in the CKD and non-CKD cohorts, respectively. When comparing renal scans at 2 and 12 months postoperation, in both groups the surgical kidney significantly recovered (both p < 0.001) and the patterns of kidney function recovery was similar in both groups (CKD +2.0%, non-CKD +1.4%, p = 0.6). On long-term follow-up (>2 years), eGFR did not change significantly in either the CKD or non-CKD group (-2.8 vs -1.1 mL/min/1.73 m2, p = 0.6). On pathology, tumors were more frequently malignant in CKD vs non-CKD patients (93.3% vs 73.2%, p = 0.02) and of higher Fuhrman Grade (grade ≥3: 49.7% vs 28.1%, p < 0.001). CONCLUSION RPN is a reasonable treatment option in patients with CKD, as it did not lead to a greater decline in renal function contributed by the surgical kidney. The patterns of kidney function recovery after surgery are similar between patients with and without CKD.
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Affiliation(s)
- Charbel Chalouhy
- 1 Department of Urology, Saint Joseph University , Beirut, Lebanon
| | - Jessica M Ruck
- 2 Department of Urology, Johns Hopkins Hospital , Baltimore, Maryland
| | - Tian Zhou
- 3 Department of Urology, Albert Einstein College of Medicine , Bronx, New York
| | - Abishek Sirvastava
- 3 Department of Urology, Albert Einstein College of Medicine , Bronx, New York
| | - Aryeh Keehn
- 3 Department of Urology, Albert Einstein College of Medicine , Bronx, New York
| | - Kara Watts
- 3 Department of Urology, Albert Einstein College of Medicine , Bronx, New York
| | - Pedro Maria
- 3 Department of Urology, Albert Einstein College of Medicine , Bronx, New York
| | - Reza Ghavamian
- 4 Northwell Health, Smith Institute of Urology , Great Neck, New York
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Zhou S, Massie AB, Luo X, Ruck JM, Chow EK, Bowring MG, Bae S, Segev DL, Gentry SE. Geographic disparity in kidney transplantation under KAS. Am J Transplant 2018; 18:1415-1423. [PMID: 29232040 PMCID: PMC5992006 DOI: 10.1111/ajt.14622] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [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: 07/30/2017] [Revised: 11/21/2017] [Accepted: 12/01/2017] [Indexed: 01/25/2023]
Abstract
The Kidney Allocation System fundamentally altered kidney allocation, causing a substantial increase in regional and national sharing that we hypothesized might impact geographic disparities. We measured geographic disparity in deceased donor kidney transplant (DDKT) rate under KAS (6/1/2015-12/1/2016), and compared that with pre-KAS (6/1/2013-12/3/2014). We modeled DSA-level DDKT rates with multilevel Poisson regression, adjusting for allocation factors under KAS. Using the model we calculated a novel, improved metric of geographic disparity: the median incidence rate ratio (MIRR) of transplant rate, a measure of DSA-level variation that accounts for patient casemix and is robust to outlier values. Under KAS, MIRR was 1.75 1.811.86 for adults, meaning that similar candidates across different DSAs have a median 1.81-fold difference in DDKT rate. The impact of geography was greater than the impact of factors emphasized by KAS: having an EPTS score ≤20% was associated with a 1.40-fold increase (IRR = 1.35 1.401.45 , P < .01) and a three-year dialysis vintage was associated with a 1.57-fold increase (IRR = 1.56 1.571.59 , P < .001) in transplant rate. For pediatric candidates, MIRR was even more pronounced, at 1.66 1.922.27 . There was no change in geographic disparities with KAS (P = .3). Despite extensive changes to kidney allocation under KAS, geography remains a primary determinant of access to DDKT.
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Affiliation(s)
- Sheng Zhou
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Allan B. Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Xun Luo
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jessica M. Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Eric K.H. Chow
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Mary G. Bowring
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sunjae Bae
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Sommer E. Gentry
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD,US Naval Academy, Annapolis, MD
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Ruck JM, Holscher CM, Purnell TS, Massie AB, Henderson ML, Segev DL. Factors associated with perceived donation-related financial burden among living kidney donors. Am J Transplant 2018; 18:715-719. [PMID: 29068176 PMCID: PMC5863761 DOI: 10.1111/ajt.14548] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [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: 07/07/2017] [Revised: 09/18/2017] [Accepted: 10/12/2017] [Indexed: 01/25/2023]
Abstract
The perception of living kidney donation-related financial burden affects willingness to donate and the experience of donation, yet no existing tools identify donors who are at higher risk of perceived financial burden. We sought to identify characteristics that predicted higher risk of perceived financial burden. We surveyed 51 living kidney donors (LKDs) who donated from 01/2015 to 3/2016 about socioeconomic characteristics, predonation cost concerns, and perceived financial burden. We tested associations between both self-reported and ZIP code-level characteristics and perceived burden using Fisher's exact test and bivariate modified Poisson regression. Donors who perceived donation-related financial burden were less likely to have an income above their ZIP code median (14% vs. 72%, P = .006); however, they were more likely than donors who did not perceive burden to rent their home (57% vs. 16%, P = .03), have an income <$60 000 (86% vs. 20%, P = .002), or have had predonation cost concerns (43% vs. 7%, P = .03). Perceived financial burden was 3.6-fold as likely among those with predonation cost concerns and 10.6-fold as likely for those with incomes <$60 000. Collecting socioeconomic characteristics and asking about donation-related cost concerns prior to donation might allow transplant centers to target financial support interventions toward potential donors at higher risk of perceiving donation-related financial burden.
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Affiliation(s)
- Jessica M. Ruck
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Tanjala S. Purnell
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD,Department of Health, Behavior, and Society, Johns Hopkins School of Public Health, Baltimore, MD
| | - Allan B. Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Macey L. Henderson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD,Johns Hopkins University School of Nursing, Baltimore, MD
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD,Johns Hopkins University School of Nursing, Baltimore, MD
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50
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Skuli SJ, Bantug ET, Zafman N, Riley C, Ruck JM, Sheng J, Smith KC, Snyder CF, Smith KL, Stearns V, Wolff AC. Abstract P6-12-21: Breast cancer survivors undergoing survivorship visits at Johns Hopkins are a high-risk population. Cancer Res 2018. [DOI: 10.1158/1538-7445.sabcs17-p6-12-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Survivorship care plans (SCPs) are strongly recommended for all breast cancer survivors to address sequelae of cancer care, plan cancer surveillance and screening, and encourage health promotion and care coordination. Ongoing studies are evaluating the impact of SCPs in cancer survivor populations and the role of survivorship visits (SVs) as an intervention. Here we describe characteristics and outcomes of patients who participated in SVs at Johns Hopkins (JH).
Methods: We retrospectively reviewed the charts of patients who participated in a SV with one of two nurse practitioners ˜1-3 months after completion of locoregional therapy and initial systemic therapy, as referred by their JH breast cancer provider. We collected patient demographics, comorbidity status, tumor characteristics, treatments received, and responses to GAD7 (generalized anxiety disorder 7-item), PHQ9 (patient health questionnaire-9), and a symptom questionnaire. Characteristics of SV participants were compared to analytical breast cancer cases from the JH Cancer Registry (JHCR 2010-2015), matched for stage.
Results: 87 women (stages I-III) who participated in a SV in 2010-2016 were identified. Compared to patients in the JHCR (n=2,942), the SV cohort was younger (age ≤50, 43% v 34%, p=0.14), more likely to be African American (33% v 22%, p=0.04), and more likely to have a higher TNM stage (I, 26% v 49%; II, 48% v 37%; III, 25% v 15%, p<0.001), node-positive status (60% v 33%, p<0.001), hormone receptor-negative disease (44% v 18%, p<0.001), and HER2-positive disease (38% v 14%, p<0.001). The SV cohort was also more likely to receive chemotherapy (94% v 43%, p<0.001) and undergo radiation therapy (78% v 54%, p<0.001). The SV cohort had a higher recurrence event rate than the JHCR cohort (11.5% v 8.0%) and a shorter median follow-up (886 v 1292 days), suggestive of a higher risk profile. In the SV cohort, a comparison of comorbidities at breast cancer diagnosis versus time of SV visit identified a significant increase in the prevalence of peripheral neuropathy (9% v 73%, p<.001), anemia (15% v 50%, p<.001), lymphedema (0% v 28%, p<.001), anxiety (15% v 38%, p<.001), and depression (13% v 29%, p<.001). Patients in the SV cohort were overweight at diagnosis (body mass index, median 29 [IQR 24, 32]). At the time of the SV, patients reported symptoms of sleep difficulty (53%), numbness or tingling (46%), weight changes (45%), muscle aches (44%), and pain (37%).
Conclusions: Patients who participated in SVs had high-risk cancers and, compared to baseline, a higher frequency of comorbidities that are potentially associated with breast cancer and its treatment. These data can inform future breast cancer survivorship care models as they describe a population that may be at greater risk for worse cancer and non-cancer outcomes, and that might benefit more from interventions like SCPs and SVs. Ongoing studies are identifying optimal target populations, appropriate timing of such interventions, and informative measures of patient-centered outcomes.
Funding: Komen Maryland/Komen Scholar SAC110053 (ACW).
Citation Format: Skuli SJ, Bantug ET, Zafman N, Riley C, Ruck JM, Sheng J, Smith KC, Snyder CF, Smith KL, Stearns V, Wolff AC. Breast cancer survivors undergoing survivorship visits at Johns Hopkins are a high-risk population [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-12-21.
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Affiliation(s)
- SJ Skuli
- Johns Hopkins University School of Medicine, Baltimore, MD; Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - ET Bantug
- Johns Hopkins University School of Medicine, Baltimore, MD; Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - N Zafman
- Johns Hopkins University School of Medicine, Baltimore, MD; Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - C Riley
- Johns Hopkins University School of Medicine, Baltimore, MD; Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - JM Ruck
- Johns Hopkins University School of Medicine, Baltimore, MD; Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - J Sheng
- Johns Hopkins University School of Medicine, Baltimore, MD; Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - KC Smith
- Johns Hopkins University School of Medicine, Baltimore, MD; Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - CF Snyder
- Johns Hopkins University School of Medicine, Baltimore, MD; Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - KL Smith
- Johns Hopkins University School of Medicine, Baltimore, MD; Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - V Stearns
- Johns Hopkins University School of Medicine, Baltimore, MD; Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - AC Wolff
- Johns Hopkins University School of Medicine, Baltimore, MD; Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD; Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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