Association between Migraine and Quality of Life, Mental Health, Sleeping Disorders, and Health Care Utilization Among Older African American Adults

PURPOSE

This study examines the associations between migraine headaches, well-being, and health care use among a sample of underserved older African American adults. Controlling for relevant variables, the association between migraine headaches and (1) health care utilization, (2) health-related quality of life (HRQoL), and (3) physical and mental health outcomes was examined.

METHODS

Our sample included 760 older African American adults from South Los Angeles recruited through convenience and snowball sampling. In addition to demographic variables, our survey included validated instruments, such as the SF-12 QoL, Short-Form McGill Pain Questionnaire, and the Geriatric Depression Scale. Data analysis included 12 independent multivariate models using multiple linear regression, log transferred linear regression, binary and multinomial logistic regression, and generalized linear regression with Poisson distribution.

RESULTS

Having migraine was associated with three categories of outcomes: (1) higher level of health care utilization measured by (i) emergency department admissions and (ii) number of medication use; (2) lower level of HRQoL and health status measured by (i) lower self-rated health (ii) physical QoL, and (iii) mental QoL; and (3) worse physical and mental health outcomes measured by (i) higher number of depressive symptoms, (ii) higher level of pain, (iii) sleep disorder, and (iv) being disabled.

CONCLUSIONS

Migraine headache significantly was associated with quality of life, health care utilization, and many health outcomes of underserved African American middle-aged and older adults. Diagnoses and treatments of migraine among underserved older African American adults require multi-faceted and culturally sensitive interventional studies.

Sources of academic stress among Iranian adolescents: a multilevel study from Qazvin City, Iran

Background

Academic stress can cause mental and physical problems and affect adolescents’ healthy development. This study aimed to estimate academic stress and explore its sources at the individual- and school levels among school-going adolescents in the city of Qazvin, Iran.

Results

This cross-sectional study used a stratified cluster sampling to recruit 1724 students aged 12–19 years from 53 schools in Qazvin City. Data were collected using a validated self-administered questionnaire. The mean academic stress score was 45.7 (95% CI 45.2, 46.3). The stress level was statistically higher among older 47.5 (95% CI 46.7, 48.3) than younger 44.1 (95% CI 43.4, 44.9) adolescents. The main academic stressors included: future uncertainty 69.7 (95% CI 68.8, 70.7), academic competition 58.5 (95% CI 57.3, 59.6), and interaction with teachers 56.1 (95% CI 55.3, 56.9). Gender, educational period, school type, family socioeconomic status, and father’s education were associated with academic stress.

Conclusions

We conducted a multilevel study using a random sample of male and female students in the city of Qazvin, Iran. Results indicated moderate levels of stress among Iranian adolescents. The academic stress was associated with several individual and school-level variables. Students and their families and teachers need education on stress prevention methods and coping mechanisms. Future research should focus on developing and testing multilevel policies and interventions to improve students’ mental health and academic performance.

Organ retrieval from brain-dead patients by a single organ procurement center in Iran

INTRODUCTION

The majority of transplantations depend solely on cadaveric organs. In recent years, special focus has been directed toward brain-dead patients in Iran, but it seems that there is limited information regarding the characteristics of cadaveric organ donation in our country.

MATERIALS AND METHODS

This is a retrospective analysis of data of our Organ Procurement Unit (OPU), which is one of the most active organ procurement units in Iran. We incorporated the data on all organ donations from brain-dead patients between 2004 and 2008 into the present study. Demographic characteristics of the patients along with data regarding brain death and organ donation were extracted from already registered data on patients.

RESULTS

Among 93 brain-dead patients registered in the database of the OPU, organs were retrieved from 85% (n = 79). Out of the 14 patients from whom no organ was retrieved, the cause for this failure was death before donation in 85% (n = 12). The numbers of donated organs varied between zero and six (mean +/- standard deviation = 3.1 +/- 1.7). The most donated organs in terms of frequency and count were: right kidney (n = 68; 73.1%), left kidney (n = 67; 72%), liver (n = 63; 67.7%), heart (n = 40; 43%), pancreas (n = 5; 5.4%), and lung (n = 4; 4.3%).

DISCUSSION

The overall organ retrieval rate from brain-dead patients by this OPU was comparable to that of developed countries; however, we still believe we can improve this rate/scale.

Medical comorbidities after renal transplantation

BACKGROUND

Despite the amount of evidence regarding the negative impact of medical comorbidities after transplantation, little attention has been directly paid to the pattern of somatic comorbidities in renal transplant recipients. The aim of this study was to assess the prevalence of medical comorbidities after kidney transplantation.

METHODS

In a cross-sectional study during 2006, we evaluated 119 kidney transplant recipients for somatic comorbidities by using the Ifudu comorbidity index, which evaluated the presence of 14 chronic illnesses among patients undergoing maintenance hemodialysis. Correlations of the Ifudu score with demographic and clinical data were also studied.

RESULTS

Eighty-three (90.4%) subjects had at least one medical comorbidity. The mean comorbidity score was 5.17 +/- 4.50. The most frequent comorbidities were nonischemic heart diseases including hypertension (n=75; 63%), visual disturbances (n=42; 35.2%), low back pain and spine and joint disorders (n=30; 25.21%), and musculoskeletal disorders (n=28; 23.5%). A higher comorbidity score was significantly correlated with lower economic status (P<.05), but not with age, gender, marital status, educational level, cause, or duration of end-stage renal disease.

CONCLUSION

The prevalence of medical comorbidities among kidney transplant recipients seems to be high, with the highest prevalence due to nonischemic heart diseases, visual disturbances, and musculoskeletal disorders. This highlighted the necessity of providing posttransplant care by a multidisciplinary team of specialists.

Renal transplantation in Iran over the past two decades: a trend analysis

BACKGROUND

In this study, we have reported updated statistics of the Iranian Transplantation Registry, the status of the recipients and grafts, and a detailed time trend with respect to patient characteristics.

METHODS

We retrospectively reviewed the Iranian Renal Transplantation Registry and information from the Dialysis and Transplant Patients Public Association, to obtain data on all kidney transplantations performed in Iran between 1986 and 2005. Data were gathered regarding the total number of transplantations, graft loss, recipient death, and donor and recipient characteristics, including demographic data, cause of end-stage renal disease (ESRD), and source of kidney. We assessed changes in variables on a biannual basis.

RESULTS

A total of 19521 transplantations were registered over the study period, of which, 761 recipients (3.9%) had died and 2333 allografts (11.9%) had been lost. The source of the kidney in 2556 (13%) subjects was a living related donor (LRD), in 16234 (83%) a living unrelated donor (LURD), and in 831 (4%) cadaveric. During the study decades we noted an increase in the number of kidney transplantations (from 22 to 3690), age of recipients (from 30 to 40), male-to-female ratio of recipients (from 0.58 to 0.67), male-to-female ratio of donors (from 0.48 to 0.52), diabetes mellitus (from 0% to 27%), and hypertension (from 4% to 15%), as causes of ESRD, as well as the use of cadaveric kidneys (0% to 11%).

CONCLUSION

Analyzing renal transplantation data not only helps to evaluate the effectiveness of transplantation activities in a country, but also provides information to estimate future costs in the health care system.

Severity of chronic pain affects health care utilization after kidney transplantation

BACKGROUND

While the association between chronic pain and high health care utilization is a known issue in the general population, this relation has not been well studied among kidney transplantation patients.

METHODS

The subjects were first-time kidney transplant recipients engrafted between 2003 and 2006 and 6 months to 5 years postoperatively. Using SF-36 Bodily Pain Scale, patients were categorized in three groups: group I, those with scores over 66.6; group II, between 66.6 and 33.3; and group III, over 33.3. The subjects' health care utilization was prospectively assessed by recording the number of hospital admission days and the frequency of home nurse visits, outpatient physician visits, and emergency department visits for any medical reason in a 6-month period.

RESULTS

A stepwise increase in the frequency of patients admitted to the hospital (P=.017), and those referred to emergency departments (P=.007) was correlated with greater severity of pain in the three groups. However, the frequency of patients having outpatient physician visits (P=.30) or home nurse visits (P=.387) did not vary significantly. Similarly, with increased pain severity, an increase was observed in the number of emergency department visits (P=.005) and duration of hospital stays (P=.049), but not in the number of home nurse (P=.890) or physician visits (P=.112).

CONCLUSION

The severity of pain seems to increase the amount of health care use among kidney transplant patients. To minimize associated costs, appropriate pain rehabilitation programs are suggested.

Transplantation research in Iran: a bibliometric study

BACKGROUND

Scientific articles are indicators of research interest and efforts in every country. The aim of the current study is to describe the characteristics of the transplantation-related research efforts with respect to the domestic published works in Iran between 1993 and 2003.

MATERIALS AND METHODS

In a descriptive design, we searched IranMedex (Iranian database for indexing medical articles; available at: http//www.iranmedex.com) for all the biomedical articles published between 1993 and 2003 in 91 Iranian journals. The search was conducted using "transplantation" and "transplant" as key words. A printed copy of the references was reviewed individually so as to identify the transplanted organ, study design, number of authors, and type of article.

RESULTS

Among 11371 articles, 545 (4.8%) were related to transplantation. An increasing trend was observed in the number of publications from 1993 to 2003. Most articles were published in Farsi (90%). The most frequently published articles were original articles (84.4%). The main subjects of were kidney (61.7%), followed by liver (12%) and bone marrow transplantation (10.8%). Cornea was the topic of research in only 3% of the papers. Of all manuscripts, 9.5% consisted of clinical trials. The mean number of authors was 3.6 +/- 2.2 (1 to 14).

CONCLUSIONS

Iranian researchers seem to be interested in the topic of transplantation; however, some fields of transplantation are neglected. This pooling of valuable information can be used by other countries, especially by researchers from the Middle East Society for Organ Transplantation region. Such databases could form an invaluable network for an exchange of experience in the region to solve common problems.

Changing treatment protocol from azathioprine to mycophenolate mofetil: decrease in renal dysfunction, increase in infections

INTRODUCTION

Immunosuppression for renal transplantation has shifted from azathioprine (AZA) regimens to those containing mycophenolate mofetil (MMF). This study investigated the impact of this change on the causes for rehospitalization as well as on graft and patient survival.

METHODS

In this retrospective cohort study, we reviewed long-term patient and graft survivals as well as the causes of posttransplant admissions for 893 kidney recipients. Data on survival and readmissions were available for 811 subjects, who were divided to into the AZA cohort (n=289, transplantation between 1998 and 1999) and the MMF cohort (n=567, transplantation between 2000 and 2001). Survival, the cause for readmission, time interval between transplantation and readmission, intensive care unit (ICU) admission, mortality, and graft loss were compared between the two cohorts.

RESULTS

Five-year patient and graft survival rates were 85% and 67% for the AZA cohort and 91% and 68% for the MMF cohort (P=.013). There were 202 (71%) and 371 (72%) readmissions registered for the AZA and MMF groups, respectively. In comparison with the AZA cohort, while readmissions secondary to graft rejection showed a significant decrease in the MMF cohort (62% vs 35%, P=.000), readmissions secondary to infections exhibited a significant increase (37% vs 50%, P=.002). A marginally significant increased mortality rate (2% vs 5%, P=.087) and ICU admission rate (3% vs 6%, P=.062) were also observed in the MMF cohort by comparison with the AZA cohort.

CONCLUSION

The shift in the immunosuppression protocol from AZA to MMF, albeit advantageous in many instances, can sometimes undermine the outcome by giving rise to such complications as high infection rates.

Prolonged rehospitalizations following renal transplantation: causes, risk factors, and outcomes

BACKGROUND

Although some studies have described rehospitalization after transplantation, few have focused on risk factors and consequences of prolonged hospital stay. Our goal was to determine the causes, risk factors, and outcomes of prolonged rehospitalizations after renal transplantation.

PATIENTS AND METHODS

In this retrospective study, 574 randomly selected rehospitalization records of kidney transplant recipients were reviewed from 1994 to 2006. Admissions were divided into group 1, prolonged stay (length of stay >14 days, n=149), and group II, short stay (length of stay <or=14 days, n=425). Demographic data, cause of end-stage renal disease (ESRD), cause of readmission, ICU admission, time interval between transplantation and rehospitalization, costs, and in-patient mortality were compared between the two groups.

RESULTS

Mean (+/-SD) hospital stay was 10.6 +/- 9.8 days. Median hospital stay was 5 days for renal stones, 7 days for surgical complications, 8 days for malignancy, 9 days for infection, and 10 days for renal dysfunction. We found higher rates of ESRD due to diabetes in group I (28% vs. 15.4%; P=.006). Admissions due to infections (56.4% vs 42.4%; P=.003) or renal dysfunctions (55% vs 41.4%; P=.004) were the cause of higher proportions of total hospitalizations with prolonged stay. Prolonged stay also correlated with higher ICU admissions (8.8% vs 2.8%; P=.002) and mortality (6.7% vs 3.05%; P=.001). Mean total hospital cost for short versus prolonged hospitalizations were US$ 586 versus US$ 2750, respectively.

CONCLUSION

In this study, we found that prolonged hospital stays accounted for >62% of all hospital costs; however, they comprised only 26% of the patients. High-risk kidney transplant recipients for prolonged hospitalizations should be closely observed for infections and graft rejection.

Does etiology of end-stage renal disease affect sleep quality in kidney transplant recipients?

BACKGROUND

That hypertension (HTN) as a leading cause of end-stage renal disease (ESRD) is linked to sleep disorders in the general population can be the basis of a hypothesis that HTN may be a contributing factor to the poor quality of sleep in some kidney transplant recipients. This study was designed to investigate the correlation between ESRD secondary to HTN and sleep quality among kidney transplant recipients.

METHODS

In this case control study, 201 kidney transplant recipients were divided into group I (ESRD) secondary to HTN, (n=82) and group II (ESRD secondary to other causes, n=119). The groups were matched for medical comorbidities, demographic and clinical data, and symptoms of anxiety and depression. Sleep quality assessed by means of the Pittsburgh Sleep Quality Index (PSQI) was compared between the study groups.

RESULTS

The mean (SD) of the total PSQI score was significantly high in group I compared with group II (7.42 +/- 2.36 vs 6.60 +/- 3.07, P=.042). Similar results were observed for the sleep duration scores in the groups (1.22 +/- 1.12 vs 0.86 +/- 1.12, P=.026). In group I, all the other PSQI components were higher than those in group II, difference that were statistically significant.

CONCLUSION

Sleep quality and duration was poorer among our kidney transplant recipients with ESRD secondary to HTN compared with the controls. Further studies, however, are required to investigate whether HTN is responsible for the reported poor quality of sleep in some kidney transplant recipients.

Sleep quality and its correlates in renal transplant patients

BACKGROUND

The aim of this study was to evaluate correlated morbidity measures with poor sleep quality among kidney transplanted patients.

METHODS

In a cross-sectional study of 125 Iranian kidney transplant patients in 2006, we employed self-administered questionnaires to evaluate the quality of sleep (PSQI), quality of life (SF-36), anxiety and depression, sexual activity, marital relationship, and medical comorbidity. Patients with PSQI score of >5 were considered to be "poor sleepers." Students t-test was used to compare the morbidity measures between the two groups: "poor sleeper" versus "good sleepers."

RESULTS

Seventy-eight (62%) patients were poor sleepers. This group showed a higher total medical comorbidity score (P=.009), more bodily pain, poorer general mental health, and less physical function on SF- 36 (P=.02), less sexual function, and more severe anxiety (P=.02). There was no significant difference between poor sleepers and good sleepers in the mean of other subscores of the SF-36, marital status, and depressive symptoms.

CONCLUSIONS

A poor quality of sleep is common after kidney transplantation. This problem is associated with higher medical comorbidity and poorer emotional state. Therefore, more attention should be paid to evaluation of sleep quality in this patient population.

[Health care units in the French blood banks, why?]

In France for several years, many patients have been treated in Blood Transfusion Centers belonging to the EFS. This partnership between public hospitals and EFS is appreciated by the patients who find a competent staff in transfusion and apheresis process, in a more pleasant environment than in hospital. There is a total of 93 Health Care Units in Blood Transfusion Centers. Sixty-three of these Health Care Units perform only transfusions and bleeding. In the remaining 30 Health Care Units apheresis, peripheral blood hematopoietic stem, cell harvesting, plasmatic exchanges and extracorporeal photopheresis are also performed. Despite the perfect fit between hospital needs, comfort and easiness for patients, an economical problem remains. At the present time, the reimbursement rate by national health insurance is below the real cost. If unsolved, this discrepancy could force an end to this beneficial partnership.

Marital Quality in Kidney Transplant Recipients: Easy to Predict, Hard to Neglect

BACKGROUND

Given the significant role of post-renal transplant familial support in the patient's adherence to treatment, a study into the contributors to marital quality in this population seems necessary. This study sought to identify the predictors of poor post-renal transplant marital quality.

METHODS

This cross-sectional study was conducted in 2006 on 125 married kidney transplant recipients. Marital quality was evaluated using the Revised Marital Adjustment Scale (RMAS). A score below the fourth-quartile MAS score of a group of age- and sex- matched healthy controls was interpreted as poor marital relationship. Multiple logistic regression analysis was utilized to evaluate the predictors of poor marital relationship.

RESULTS

The mean time interval between transplantation and assessment of marital quality was 43 +/- 15 months. Poor post-renal transplant marital quality can be predicted by the kidney transplant recipient's sex (M/F) (odds ratio [OR]; 0.31; 95% confidence interval [CI], 0.11 to 0.90; P=.031), age at transplantation (OR, 0.93; 95% CI, 0.89 to 0.98; P=.005), educational level (OR, 0.67; 95% CI, 0.44 to 1.03; P=.067), and monthly family income (OR, 2.20; 95% CI, 1.09 to 4.44; P=.028).

CONCLUSION

Presenting a simple prediction model for poor post-renal transplant marital relationship, this study will make it possible to detect patients at a higher risk of poor marital quality and thus avoid treatment noncompliance. At the time of transplantation, using simple demographic variables and providing couple-based health education programs as a part of a familial approach to renal transplantation may improve the outcome of such high-risk patients.

Kidney Transplantation: Is There Any Place for Refugees?

There are more than 8 million refugees worldwide with the Middle East bearing the brunt. Socioeconomic factors are the major obstacles that refugees encounter when seeking health care in the host country. It, therefore, comes as no surprise that refugees are denied equal opportunities for one of the most sophisticated and expensive medical procedures in the world, kidney transplantation. With respect to transplantation, refugees are caught between a rock and a hard place: as recipients they have to single-handedly clear many hurdles on the arduous road to renal transplantation and as donors they are left unprotected against human organ trafficking. It should be the moral responsibility of the host country to provide this population with a support network. The ways and means of establishing this network should be defined locally; nevertheless, enabling refugees to receive a transplant is the most basic step, which should be followed by the provision of financial support and follow-up facilities in a concerted effort to ensure the continued function of the invaluable graft. It is also necessary that refugees be protected from being an organ reservoir on the black market. There are no precise regional or international data available on kidney transplantation in refugees; among the Middle East Society for Organ Transplantation countries, only Iran, Saudi Arabia, Pakistan, and Turkey have thus far provided data on their respective kidney transplantation regulations and models. Other countries in the region should follow suit and design models tailored to the local needs and conditions. What could, indubitably, be of enormous benefit in the long term is the establishment of an international committee on transplantation in refugees.

Which Primary Diagnosis Has the Highest in-Hospital Mortality Rate for Kidney Recipients?

OBJECTIVES

Although "in-hospital mortality" for several post-renal transplantation complications has been reported in various studies, there is no single published single-center study that compares their hospital mortality rates. We sought to rank the primary diagnoses post-renal transplantation by means of in-hospital mortality.

METHODS

We selected 404 consecutive rehospitalizations following kidney transplantation from 2003 to 2005. The causes of rehospitalization were categorized into infection, allograft rejection, surgical complication, cerebrovascular accidents (CVA), malignancy, medication complications, and miscellaneous. Fatality was defined as the relative frequency of death due to the same cause among all admissions.

RESULTS

The mortality rate (MR) was 5.7%. From the 23 cases of death, 17 (74%) had a functioning kidney at the time of death. The MR was 40% for CVA, 14.3% for surgical complications, 11.1% for miscellaneous, 5.3% for drug complications, 7% for infections, and 4.8% for graft rejection (P=.002). No death was observed among cases with a diagnosis of malignancy or nephrolithiasis. Inpatient mortality was higher among those with more than one diagnosis at admission: 42.9% for more than two diagnosis, 7.1% for those with two diagnosis, and 4.2% for those with one diagnosis (P=.001).

CONCLUSIONS

The in-patient mortality ranking is totally different from the ranking of causes of death in renal recipients. In other words, infection is the leading cause of death due to high incidence, and not high fatality. More rare complications, including CVA and surgical complications, are more often fatal.

Consignes transfusionnelles en cas d’allogreffe de cellules souches hématopoïétiques

Hematopoietic stem cell (HSC) allogeneic transplantation is now commonly used as a therapeutic tool in patients with certain types of hematologic malignancies. Such patients, on account of severe pre-graft conditioning regimens, present with severe marrow aplasia justifying specific transfusion care. Given a complex immunological situation (immediately after transplantation, co-existence of two cell populations with different immunohematological characteristics), transfusion protocols must rest on clear and well-defined recommendations. Recent transfusion recommendations in settings of HSC allogeneic transplantation have defined criteria for the choice of blood products (red blood cell concentrates, plasma and platelet concentrates) depending on recipient and graft immunohematological characteristics (minor/major/mixed ABO compatibility/incompatibility and time of transplantation). Transfusion instructions are summarized in a synthesis document entitled : "Instructions for transfusion following HSC allogeneic transplantation". This document specifies the immunohematological characteristics of blood products and various transfusion protocols (systematic irradiation, negative CMV, etc.). This document is used by the teams who distribute blood products, for selection purposes, as well as by the medical transfusion team when they perform ultimate pre-transfusion control steps.

Primary Kidney Disease and Post–Renal Transplantation Hospitalization Costs

BACKGROUND AND AIM

This study sought to assess posttransplantation hospitalizations costs in diabetic and nondiabetic subjects to see whether diabetes mellitus (DM) as a primary cause of end-stage renal disease (ESRD) increased posttransplantation hospitalization costs.

METHODS

From 2000 to 2005, the hospitalization costs of 387 consecutive rehospitalizations of kidney recipients were retrospectively compared for two groups: patients with ESRD due to DM (n=71) and those with ESRD of non-DM etiologies (n=316). The hospitalization costs included the costs of hotel, medications, surgical procedures, paraclinical tests, imaging tests, health personnel time, special services (ie, patient transportation by ambulance), and miscellaneous costs. Societal perspective was used with costs expressed in PPP$ purchase power parity dollars (PPP$) estimated to be equal to 272 Iranian rials.

RESULTS

Compared with the non-DM group, DM patients experienced significantly higher median costs both in total (1262 vs 870 PPP$, P=.001) and in cost components related to hotel (384 vs 215 PPP$, P=.001), health personnel time (235 vs 115 PPP$, P<.001), paraclinical tests (177 vs 149 PPP$, P=.012), and special services (100 vs 74 PPP$, P=.041). The mean of age was higher (P<.001), and the transplantation hospitalization time interval was also shorter in the DM group (median: 2.7 vs 12, P=.025).

CONCLUSIONS

Considering DM as a leading cause of ESRD and its increasing prevalence in some countries, the association between hospitalization costs of posttransplant patients and DM may be of great economic importance to many transplantation centers.

Prediction of Inpatient Survival and Graft Loss in Rehospitalized Kidney Recipients

INTRODUCTION

Despite a sizeable amount of research conducted hitherto into predictors of renal transplantation outcomes, there are scarce, data on predictors of in-hospital outcomes of post-kidney transplant rehospitalization. This study sought to provide a user-friendly prediction model for inpatient mortality and graft loss among rehospitalized kidney recipients.

METHOD

This retrospective review of 424 consecutive kidney recipients rehospitalized after kidney transplantation between the years 2000 and 2005 used multiple logistic regression analysis to evaluate predictors of hospitalization outcomes.

RESULTS

Multivariate analysis showed that age at admission, diabetes mellitus as the cause of end-stage renal disease (ESRD), admission due to cerebrovascular accident (CVA), surgical complications were predictors of in-hospital death; age at transplantation, surgical complications, and rejection were predictors of graft loss. Equation for prediction of in-hospital death was Logit(death) -0.304 * age at transplantation (year) + 0.284 age at admission (year) + 1.621 admission for surgical complication + 4.001 admission for CVA-ischemic heart disease + 2.312 diabetes as cause of ESRD. Equation for prediction of in-hospital death was Logit(graft loss) = 0.041 age at transplantation (year) + 1.184 admission for graft rejection + 1.798 admission for surgical complication.

CONCLUSIONS

Our prediction equations, using simple demographic and clinical variables, estimated the probability of inpatient mortality and graft loss among re-hospitalized kidney recipients.

Hospitalization Databases: A Tool for Transplantation Monitoring

INTRODUCTION

We sought to account for changes in posttransplant hospitalization patterns in terms of the changes in demographic and transplantation-related variables.

METHODS AND MATERIALS

We retrospectively analyzed 1860 cases of kidney transplantation performed between 1992 and 2004 in terms of demographic and transplantation-related variables. Of the 1860 cases, rehospitalization records in the first year posttransplantation were available for 1152 cases, which were assessed for causes of admission, mortality, graft loss, length of stay, and hospital charges.

RESULTS

The pattern of rehospitalizations showed the following trends: (1) Increased rate of infection; (2) Decreased rate of graft rejection; and (3) Peak costs of rehospitalization between 1999 and 2000.

CONCLUSION

We believed that the increased infection rate and decreased rejection rate may have been related at least partly to the shift in the treatment protocol from azathioprine-based to mycophenolate mofetil regimens in 2000. Furthermore, the peak in the relative frequency of diabetes mellitus and hypertension as the etiology of end-stage renal disease among those having undergone transplantation between 1999 and 2000 may have been responsible for the peak in rehospitalization costs and length of hospital stay. We are strongly of the opinion that hospital statistics are a valuable tool for health care policymakers to monitor transplantation outcomes.

The Outcome of Diverticulosis in Kidney Recipients With Polycystic Kidney Disease

INTRODUCTION

Diverticulosis is a common finding in autosomal-dominant polycystic kidney disease (ADPKD). To avoid the serious complications of diverticulosis after kidney transplantation, some policies have recommended aggressive actions, such as elective colectomy. These policies are not widely agreed upon. This controversy led us to investigate the serious complications and the outcome of diverticulosis in ADPKD kidney recipients to see whether such therapies are justified.

MATERIALS AND METHODS

From 2002 to 2006, we followed 18 ADPKD kidney recipient patients with barium enema-documented diverticulosis. All subjects were asymptomatic for diverticulosis at the time of transplantation. The mean value +/- SD of follow-up duration was 25.4 +/- 28.5 months. We documented demographic data, familial history of ADPKD, barium enema findings, and complications as well as graft and patient survivals.

RESULTS

Hepatic flexure was the most prevalent site for diverticula. The mean (SD) of diverticular count was 6 +/- 5.1. Patients with a familial history of ADPKD showed a higher number of diverticular (P=.01). Diverticulitis occurred in three patients, all of whom died.

CONCLUSION

Diverticulitis is a fatal and not rare complication in ADPKD patients. The rate of complications in our study was similar to previous findings, but we observed serious complications even among patients asymptomatic at the time of transplantation. The decision to take aggressive action such as elective colectomy is still a matter of debate that needs further evaluation.

Outcome of Living Kidney Transplant: Pediatric in Comparison to Adults

BACKGROUND

Renal transplantation is the most optimal way to manage children with end-stage renal disease. Despite its benefits, pediatric renal transplantation is a challenge for several transplantation centers in terms of achieving a satisfactory outcome. We sought to compare the long-term outcome of pediatric versus adult recipients who underwent renal transplantation.

METHOD

We examined, 2631 recipients of a first kidney from a living donor between 1982 and 2002. The two groups were matched for immunosuppressive therapy and number of HLA mismatches. The patients were divided into a pediatric (n=301; age <or= 18 years) and an adult group (n=2330; age > 18 years) to compare 5-year patient and graft survivals.

RESULTS

The mean ages of the pediatric and adult groups were 40 +/- 13 and 14 +/- 13 years, respectively. The 5-year graft survival was lower among the pediatric versus the adult group (56% vs 68%; P=.015) with no difference in patient survival (88% vs 86%; P>.05).

CONCLUSION

The poorer graft survival in pediatric transplantation may be due to the nature of pediatric transplantation, in terms of inconsistent adherence to medication regimens, worse side effects of medications, higher rate of graft rejection due to recurrent disease, and more intense immunoreactivity of children.

The Cost of Kidney Transplantation in Iran

BACKGROUND

Kidney transplantation has gained widespread popularity by improving the outcome of end-stage renal disease (ESRD) patients. However, this is a highly complicated and expensive procedure that puts much pressure on the health system in developing countries. We report the costs in Iran model of kidney transplantation.

MATERIALS AND METHODS

We reviewed the regulations for kidney transplantation using Dialysis and Transplant Patients Association (DATPA) information, 2005. All data regarding the cost of transplantation procedure, immunosuppression, and the money given to donors were included. The cost of transplantation procedure was categorized into personnel, drugs, paraclinics, hospital bed, and other expenses. To achieve more comprehensive results, all costs were converted into US dollars (1 USD = 9000 Rials).

RESULTS

The total cost of kidney transplantation procedure was $9224. Of this, 65.8% ($6076) was related to the immunosuppression therapy in the first year, 22.2% ($2048) to the transplantation procedure, and 12% ($1100) to organ procurement. The details of donor nephrectomy were as follows: personnel, $183; accommodations, $107; drugs, $39; paraclinics, $23; and other, $22. These values for kidney recipient were personnel, $331; drugs, $367; paraclinics, $278; accommodations, $475; and other, $222.

CONCLUSION

Compared with other countries, the kidney transplantation cost is low in Iran. The health system also pays for all the expenses. These, along with full medical insurance coverage of kidney recipients, make kidney transplantation available for every patient, regardless of the socioeconomic status due to its low cost. It is expected that a higher number of transplantation candidates with a low socioeconomic status will select transplantation.

Anxiety and Depression Are Correlated With Higher Morbidity After Kidney Transplantation

BACKGROUND

Psychiatric comorbidities have been reported to be associated with low quality of life, but less attention has been paid to their impact on other morbidity measures. The aim of this study was to investigate the correlation of anxiety and depression with marital relation, sexual function, and sleep quality in kidney transplant recipients.

METHODS

In a cross-sectional study between 2005 and 2006, 88 kidney transplant recipients were divided into four groups according to their scores of anxiety and depression using Hospital Anxiety Depression Scale (HADS): group I(anx) (anxiety score <11; n=64); group II(anx) (anxiety score >or= 11; n=24); group I(dep) (depression score <11; n=68); and group II(dep) (depression score >or= 11; n=20). Morbidity measures including quality of life (Short Form-36), marital adjustment (Revised Dyadic Adjustment Scale), sexual relationship (Relationship and Sexuality Scale), and quality of sleep (Pittsburgh Sleep Quality Index) were separately compared between groups of anxious versus nonanxious and depressed versus nondepressed.

RESULTS

Group I(anx), compared with group II(anx), displayed a better state of mental health (48.80 +/- 7.14 vs. 44.45 +/- 7.80; P=.01), general health (49.36 +/- 12.77 vs. 42.91 +/- 16.67; P=.05), marital adjustment (55.13 +/- 8.01 vs. 48.35 +/- 16.62; P=.04), and lower sleep disturbance (1.36 +/- 0.62 vs. 1.66 +/- 0.63; P=.05). Group I(dep), compared with group II(dep), showed lower fatigue score (39.79 +/- 8.30 vs. 46.84 +/- 8.85; P=.002) and better sexual relationships (15.28 +/- 5.50 vs. 19.00 +/- 5.92; P=.03).

CONCLUSIONS

Screening for anxiety and depression in kidney transplant recipients is essential. Appropriate treatment of these prevalent psychiatric comorbidities may improve various aspects of patient well-being, including quality of life, sleep, marital relations, and sexual relationship.

A Logistic Regression Model for Predicting Health-Related Quality of Life in Kidney Transplant Recipients

BACKGROUND

To develop a logistic regression model capable of predicting health-related quality of life (HRQOL) among kidney transplant recipients and determine its accuracy.

METHODS

Three groups of patients were selected: 70 healthy controls, 136 kidney transplant patients as a derivation set, and another 110 kidney transplant patients as a validation set. SF-36 score was used for HRQOL measurement. A cutoff point to define poor versus good HRQOL was calculated using the SF-36 scores of healthy controls. A logistic regression model was used to derive predictive parameters from the derivation set. The derived model was then tested among the validation set. HRQOL predictions made by the model for the patients in the validation set and the SF-36 scores were compared. We calculated sensitivity, specificity, positive and negative predictive values, and model accuracy.

RESULTS

SF-36 scores below 58.8 were defined as an indication of poor HRQOL. The regression model suggested that poor HRQOL was positively associated with lower education (below high school diploma), being single or widowed, and diabetes/hypertension as etiology. It was negatively associated with younger age (<45 years) at the time of transplantation. Optimal sensitivity and specificity were achieved at a cutoff value of 0.74 for the estimated probability of poor HRQOL. Sensitivity, specificity, positive and negative predictive values, and accuracy of the model were 73%, 70%, 80%, 60%, and 72%, respectively.

CONCLUSION

The suggested model can be used to predict poor posttransplant HRQOL among renal graft recipients using simple variables with acceptable accuracy. This modal can be of use in decision making in the recipients for whom achieving good HRQOL is the main aim of transplantation, to select high-risk patients and to start interventional programs to prevent a poor HRQOL.

Ex vivo expansion of megakaryocyte precursor cells in autologous stem cell transplantation for relapsed malignant lymphoma

To evaluate the impact of ex vivo expanded megakaryocyte (MK) progenitors on high-dose chemotherapy-induced thrombocytopenia, we conducted a phase II study in 10 patients with relapsed lymphoma. Two fractions of peripheral blood progenitor cells (PBPC) were cryopreserved, one with enough cells for at least 2 x 10(6) CD34+ cells/kg and a second obtained after CD34+ selection. Ten days before autologous stem cell transplantation, the CD34+ fraction was cultured with MGDF+SCF for 10 days. After BEAM (BCNU, cyclophosphamide, cytarabine, and melphalan) chemotherapy, patients were reinfused with standard PBPC and ex vivo expanded cells. No toxicity was observed after reinfusion. The mean fold expansion was 9.27 for nucleated cells, 2 for CD34+ cells, 676 for CD41+ cells, and 627 for CD61+ cells. The median date of platelet transfusion independence was day 8 (range: 7-12). All patients received at least one platelet transfusion. In conclusion, ex vivo expansion of MK progenitors was feasible and safe, but this procedure did not prevent BEAM-induced thrombocytopenia. Future studies will determine if expansion of higher numbers of CD34+ cells towards the MK-differentiation pathway will translate into a functional effect in terms of shortening of BEAM-induced thrombocytopenia.

In vitro generation of dendritic cells from human blood monocytes in experimental conditions compatible for in vivo cell therapy

DC are professional APC that are promising adjuvants for clinical immunotherapy. Methods to generate in vitro large numbers of functional human DC using either peripheral blood monocytes or CD34+ pluripotent HPC have been developed recently. However, the various steps of their in vitro production for further clinical use need to fit good manufacturing practice (GMP) conditions. Our study focused on setting up such a full procedure, including collection of mononuclear cells (MNC) by apheresis, separation of monocytes by elutriation, and culture of monocytes with GM-CSF + IL-13 + autologous serum (SAuto) in sterile Teflon bags. The procedure was first developed with apheresis products from 7 healthy donors. Its clinical feasibility was then tested on 7 patients with breast cancer. The characteristics of monocyte-derived DC grown with SAuto (or in some instances with a pooled AB serum) were compared with those obtained in the presence of FBS by evaluation of their phenotype, their morphology in confocal microscopy, and their capacity to phagocytize latex particles and to stimulate allogeneic (MLR) or autologous lymphocytes (antigen-presentation tests). The results obtained demonstrate that the experimental conditions we set up are easily applicable in clinical trials and lead to large numbers of well-defined SAuto-derived DC as efficient as those derived with FBS.

Experience with living related donor nephrectomy: Evaluation of 200 cases

Over a ten year period (1979 to 1989), 200 patients have undergone live donor nephrectomy through a flank extraperitoneal approach without rib resection. The average hospital stay was short and the major complications were negligible. Early graft function was seen in 97% of the cases. Delayed function due to acute tubular necrosis developed in 3%. Urinary leak was seen in 3%. Two kidneys were lost due to infection related to urinary fistulate. In 70 donors, 37 +/- 13 month's follow-up was available. Hypertension developed in two patients three and three and one-half years post donation. Significant proteinuria (>300 mg/day) was noted in one patient. No significant renal functional abnormalities were observed. Creatinine clearance was about 70% of the initial measurement at the observation time. We conclude that extraperitoneal flank live donor nephrectomy is generally safe and associated with minimal perioperative and long-term morbidity. Moreover, the procedure provides an excellent allograft function.