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

RATIONALE & OBJECTIVE

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

STUDY DESIGN

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

SETTING & PARTICIPANTS

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

ANALYTICAL APPROACH

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

RESULTS

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

LIMITATIONS

Potential selection bias.

CONCLUSIONS

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

PLAIN-LANGUAGE SUMMARY

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

The Perspectives of General Nephrologists Toward Transitions of Care and Management of Failing Kidney Transplants

The management of failing kidney allograft and transition of care to general nephrologists (GN) remain a complex process. The Kidney Pancreas Community of Practice (KPCOP) Failing Allograft Workgroup designed and distributed a survey to GN between May and September 2021. Participants were invited via mail and email invitations. There were 103 respondents with primarily adult nephrology practices, of whom 41% had an academic affiliation. More than 60% reported listing for a second kidney as the most important concern in caring for patients with a failing allograft, followed by immunosuppression management (46%) and risk of mortality (38%), while resistant anemia was considered less of a concern. For the initial approach to immunosuppression reduction, 60% stop antimetabolites first, and 26% defer to the transplant nephrologist. Communicating with transplant centers about immunosuppression cessation was reported to occur always by 60%, and sometimes by 29%, while 12% reported making the decision independently. Nephrologists with academic appointments communicate with transplant providers more than private nephrologists (74% vs. 49%, p = 0.015). There are heterogeneous approaches to the care of patients with a failing allograft. Efforts to strengthen transitions of care and to develop practical practice guidelines are needed to improve the outcomes of this vulnerable population.

Alloreactivity and autoreactivity converge to support B cell epitope targeting in transplant rejection

Antibody (Ab) responses against human leukocyte antigen (HLA) proteins mismatched between donor and recipient are leading cause of allograft loss in kidney transplantation. However, therapies targeting alloreactive B cell and Ab-secreting cell (ASC) are lacking, motivating the need to understand how to prevent and abrogate these alloresponses. Using molecular, structural, and proteomic techniques, we profiled the B cell response in a kidney transplant recipient with antibody-mediated rejection and graft loss. We found that this response spanned the rejected organ and peripheral blood, stimulated the differentiation of multiple B cell subsets, and produced a high-affinity, donor-specific, anti-HLA response. We found epitopic immunodominance that relied on highly exposed, solvent-accessible mismatched HLA residues as well as structural and biomolecular evidence of autoreactivity against the recipient's self-HLA allele. These alloreactive and autoreactive signatures converged in the recipient's circulating donor-specific Ab repertoire, suggesting that rejection requires both the recognition of non-self and breaches of tolerance to lead to alloinjury and graft loss.

COVID-19 Vaccination and Remdesivir are Associated With Protection From New or Increased Levels of Donor-Specific Antibodies Among Kidney Transplant Recipients Hospitalized With COVID-19

Alloimmune responses in kidney transplant (KT) patients previously hospitalized with COVID-19 are understudied. We analyzed a cohort of 112 kidney transplant recipients who were hospitalized following a positive SARS-CoV-2 test result during the first 20 months of the COVID-19 pandemic. We found a cumulative incidence of 17% for the development of new donor-specific antibodies (DSA) or increased levels of pre-existing DSA in hospitalized SARS-CoV-2-infected KT patients. This risk extended 8 months post-infection. These changes in DSA status were associated with late allograft dysfunction. Risk factors for new or increased DSA responses in this KT patient cohort included the presence of circulating DSA pre-COVID-19 diagnosis and time post-transplantation. COVID-19 vaccination prior to infection and remdesivir administration during infection were each associated with decreased likelihood of developing a new or increased DSA response. These data show that new or enhanced DSA responses frequently occur among KT patients requiring admission with COVID-19 and suggest that surveillance, vaccination, and antiviral therapies may be important tools to prevent alloimmunity in these individuals.

Thirty Years of Tacrolimus in Clinical Practice

Tacrolimus was discovered in 1984 and entered clinical use shortly thereafter, contributing to successful solid organ transplantation across the globe. In this review, we cover development of tacrolimus, its evolving clinical utility, and issues affecting its current usage. Since earliest use of this class of immunosuppressant, concerns for calcineurin-inhibitor toxicity have led to efforts to minimize or eliminate these agents in clinical regimens but with limited success. Current understanding of the role of tacrolimus focuses more on its efficacy in preventing graft rejection and graft loss. As we enter the fourth decade of tacrolimus use, newer studies utilizing novel combinations (as with the mammalian target of rapamycin inhibitor, everolimus, and T-cell costimulation blockade with belatacept) offer potential for enhanced benefits.

Outcomes in Simultaneous Liver Kidney Transplants in the Setting of a Positive Crossmatch: A Single Center Experience

Recent literature suggests that a positive crossmatch adversely impacts outcomes in simultaneous liver-kidney transplant (SLKT). The aim of this study was to evaluate outcomes of SLKT with a positive flow crossmatch (+FCXM) at our center. We retrospectively analyzed all of the SLKTs between January 1, 2000, and September 30, 2010. A total of 2793 kidney transplants and 892 liver transplants were performed in this time period, of which, 31 were SLKT (3%). Seven of the 31 (22%) SLKTs had a +FCXM. There were 3 major adverse events: 1 patient mortality at 9 months with liver failure; 1 allograft nephrectomy for primary nonfunction secondary to hyper-acute rejection; and, 1 recurrent liver allograft rejection with eventual graft loss and death at 26 months post-transplant. The median follow-up time was 34 months. The 3-year overall SLKT patient survival in the negative FCXM (-FCXM) patients was 85% compared with 71% in the +FCXM group. The rates of acute liver and kidney rejection were 6% and 10%, respectively, in the -FCXM group compared to 14% and 28%, respectively, in the +FCXM group. A very strongly +FCXM with a mean channel shift above 4 times the positive cut-off and the presence of multiple strong donor-specific antibodies (DSA) with mean fluorescence intensity (MFI) above 10,000 were associated with poorer outcome. In conclusion, in patients with very strongly +FCXM with high MFI DSA, proceeding with the transplantation leads to poor outcomes.

The novel use of three-dimensional surface models to quantify and visualise the immediate changes of the mid-facial skeleton following rapid maxillary expansion

BACKGROUND

The transverse skeletal effects of rapid maxillary expansion (RME) have previously been assessed using cone-beam CT (CBCT). However, to date the majority of studies assess the changes based on two-dimensional slice images, which under utilises the three-dimensional (3D) data captured. This study optimizes the volumetric CBCT data by generating 3D rendered surface models to quantity and visualize the immediate 3D changes of the mid-facial bone surfaces following RME.

METHODS

The sample consisted of 14 patients who required RME prior to fixed appliances. Pre-treatment (T0) and immediate post expansion (T1) CBCT images were taken. Following superimposition the mid face was divided into six anatomical regions. A one-sample t-test was used to determine if the differences between the two surfaces were significantly ≥0.5 mm.

FINDINGS

All regions showed a change following RME ≥ 0.5 mm. The maxillary and nasal bones showed 2.3 mm and 2.4 mm expansion respectively, followed by the zygomatic bones (1.4 mm), 2 cases showing asymmetric expansion.

CONCLUSIONS

The use of 3D surface rendered models allows quantification and visualisation of 3D changes in the mid-facial skeleton at anatomical sites distant of RME activation. Following activation there can be a pan mid-facial expansion, including not only the maxilla but also the nasal lateral bones and zygomas. The response was highly variable and asymmetric expansion can occur.

Genetic variability of Blastocystis sp. isolates obtained from cancer and HIV/AIDS patients

This represents the first study to determine the genetic diversity of Blastocystis sp. among cancer and HIV/AIDS patients. Forty Blastocystis sp. isolates obtained from 20 cancer and 20 HIV/AIDS patients were genotyped by PCR using seven pairs of known sequenced-tagged site primers. Out of the 40 isolates, 38 were identified as one of the known genotypes and two isolates were negative with all the STS primers. Blastocystis sp. subtype 3 which is reported to be associated with disease was found to be predominant among the study subjects.

Cultural adaptation and validation of a questionnaire for use in hepatitis B patients

Health-related quality of life (HRQoL) is an important aspect of the overall management of hepatitis B virus (HBV) infection. The major challenge is to find a valid and reliable disease-specific HRQoL instrument designed specifically for measuring health status in hepatitis B patient. Consequently, this study was undertaken to adapt culturally the Hepatitis Quality of Life Questionnaire (HQLQ) and assess its suitability for use in English-speaking hepatitis B virus-infected (HBV) patients in Singapore. Two patient focus groups were conducted to facilitate the cultural adaptation of the HQLQ. Reliability was assessed using Cronbach's alpha coefficients and intraclass correlation coefficients. Item-to-scale correlation was assessed using Spearman's rank correlations (rho) between scale scores and their constituent items. Convergent and divergent construct validities were tested in three and two a priori hypotheses, respectively, and the correlations were assessed using Spearman's rank correlation coefficients (rho). The culturally adapted questionnaire was tested in 298 HBV patients. The test-retest reliability was supported with 10 of the 12 scales showing acceptable correlation coefficients (i.e. alpha>0.7). Item-to-scale correlations were good with most items highly correlated with their hypothesized scales. Convergent and divergent construct validities were supported by the presence of hypothesized correlations between the HQLQ and the EQ-5D domains (eight of 10 sub-hypotheses for convergent construct validity and all hypotheses for divergent construct validity were fulfilled). In conclusion, our results showed that the culturally adapted HQLQ has good validity and reliability, making it a potentially useful outcome measure in the evaluation of HBV patients in Singapore.

How big is the financial burden of hepatitis B to society? A cost-of-illness study of hepatitis B infection in Singapore

Hepatitis B virus (HBV) infection is the most common cause of chronic viral liver disease in Singapore. Nevertheless, very little data exist on the financial burden of HBV infection to the society as a whole. The aim of this study was therefore to assess the direct and indirect cost of HBV infection in a cost-of-illness analysis. The combined data from the direct and indirect cost with the estimated prevalence for different disease stages of HBV infection would represent the annual financial burden of HBV infection to the Singaporean society as a whole. The estimated total annual cost of chronic HBV infection and its associated complications in Singapore was US$279 million (range US$34-941 million when allowing various assumptions as tested by the sensitivity analyses), with 58% or US$161 million attributable to direct cost. Based on the base-case estimation, total direct cost alone is equivalent to 12% of the national healthcare expenditure for 2003. The total cost incurred by chronic hepatitis B patients represents the biggest cost component, followed by decompensated cirrhosis (DC) patients. The ratio of direct to indirect costs based on the base-case estimation increased with disease severity, with the highest ratio obtained for the post-liver transplants (40.2:1), followed by hepatocellular carcinoma (7.4:1) and DC patients (2.7:1). The results of this study suggest that the management of HBV infection poses more than a medical challenge as it is a sizeable economic burden from both the payer and societal perspectives.

Enterolith formation in the roux limb hepaticojejunostomy

Enterolith in the Roux limb of Roux-en-Y hepaticojejunostomy is rare. We report a case of a Roux loop enterolith presenting with recurrent cholangitis. Cholescintigraphy and magnetic resonance imaging aided in the preoperative diagnosis. Intraoperatively, a large enterolith was extracted distal to the biliodigestive anastomosis. A kink of the small bowel was also noted distal to the stone. The mechanism for enterolith formation in the Roux loop is discussed.

Initial experience in use of fluorine-18-fluorodeoxyglucose positron emission tomography/computed tomography in thyroid carcinoma patients with elevated serum thyroglobulin but negative iodine-131 whole body scans

INTRODUCTION

This study aims to examine the usefulness of fluorine-18-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) in thyroid carcinoma patients with elevated serum thyroglobulin (Tg) but negative iodine-131 (I-131) whole body scans.

METHODS

17 patients with differentiated thyroid carcinoma who underwent FDG PET/CT scans were reviewed retrospectively over a period of one year from July 2003 to June 2004. All these patients had completion thyroidectomy and subsequently presented with elevated serum Tg but negative post-therapy I-131 whole body scans. Nine of these patients underwent FDG PET/CT in a hypothyroid state, while the remainder underwent FDG PET/CT while on thyroxine replacement.

RESULTS

15 out of 17 PET/CT scans revealed lesions consistent with metastases, giving a sensitivity of 88.2 percent. Four of these patients were amendable to surgical treatment. Two scans were negative.

CONCLUSION

FDG PET/CT is a sensitive diagnostic tool to detect radioiodine-negative recurrences/metastases in patients with thyroid carcinoma. Our preliminary results are comparable with published results based on PET.

Plate osteosynthesis of the humerus shaft fracture an its association with radial nerve injury--a retrospective study in Melaka General Hospital

Over a seven-year period, 170 cases of humerus fractures were plated in Hospital Melaka. Of these, 131 cases were successfully traced for this study. Besides looking at fracture epidemiology, its relationship with radial nerve injury was examined. The incidence of post-traumatic wrist drop in closed and compound fractures were 14.9% and 35.3% respectively. In relation to the site of fracture, lower third fracture had the highest incidence of wrist drop (29%). The recovery from post-traumatic wrist drop was 83%. The average duration taken for recovery was 11.8 weeks. The incidence of post-operative wrist drop was high at 17.6% but all recovered during follow-up.

Detection of Helicobacter pylori from endoscopic biopsies and the biochemical characteristics of these isolates

Helicobacter pylori (formerly Campylobacter pylori) has been recently described as a gastritis-associated bacterium. We examined endoscopic biopsies of 100 patients with dyspepsia and found H. pylori in the gastric antrum of 34 (34%) by either culture, urease tests and/or histology. Thirty-one out of 41 patients (75.6%) confirmed to have chronic active gastritis histologically had H. pylori in their gastric antrum compared to 3 out of 59 patients (5.1%) with dyspepsia but normal histology (p less than 0.01). Histological examination, using gram stain and the Warthin-Starry Silver stain, detected 29 of the 34 positive cases (85.3%); urease test, 26 cases (76.5%) and culture, 22 cases (64.7%). A combination of histological examination and urease test increased the detection rate to 97.1%. Therefore we felt that for the detection of H. pylori in endoscopic biopsies, culture, which is time consuming and expensive, is not necessary in routine diagnosis as it did not improve the diagnostic rate over a combination of histology and urease test. A comparative study on three media (blood agar, chocolate agar and Skirrow's agar) used in the isolation of the organism showed that non-selective blood agar and chocolate agar were superior to Skirrow's agar. The strains isolated appeared to be homogeneous in their morphological and biochemical characteristics.

Elevated plasmz zinc: a heritable anomaly

An extremely high concentration of zinc in the plasma (hyperzincemia) was found in five out of seven members of one family and in two out of three second generation indiviuals, an indication that the condition is heritable. The excess zinc in the plasma appears to be bound to serum proteins, with no apparent clinical symptoms or abnormalities.