Progress in Transplantation

Many young transplant patients (≤11 years old) struggle to take their immunosuppressive and co-medications correctly, yet it remains unclear which factors positively or negatively affect medication adherence. Research studies on determinants in this age group are scarce, have methodological flaws, and focus exclusively on immunosuppressants or on barriers rather than on facilitators.

This study used a consecutive mixed-methods (qualitative + quantitative) design. Semistructured interviews with parents of 10 pediatric liver or kidney transplant recipients 2 to 11 years old on adherence facilitators and barriers were conducted, complemented by quantification of adherence to the immunosuppressants and co-medications, and completion of the “immunosuppressive medication adherence barriers” self-report instrument.

A median of 19 (range, 10–29) barriers was reported: the most commonly encountered were forgetfulness (70%), vomiting (70%), bad taste (60%), and interruptions in routine (60%). Parents reported a median of 15 facilitators (range, 6–26), including using practical aids (100%), having medication with you at all times (100%), having to take fewer medications (80%), and experiencing fewer regimen changes over time (80%). No clear distinction between immunosuppressants or co-medications was made.

This study provides several new insights based on peer experience to support future patients and their parents in medication adherence.

To evaluate the role of prophylactic versus selective ureteric stenting in the development of postoperative ureterovesical complications in kidney transplant recipients.

Records of 614 transplant patients seen from January 2006 to May 2011 were retrospectively reviewed. The primary outcome was the rate of ureterovesical complications, defined as the development of ureteric obstruction or a ureterovesical anastomotic leak. The secondary outcomes were the rate of urinary tract infections and forgotten stents. Using a χ² test, we compared the primary and secondary outcomes across the selective and prophylactic cohorts. Logistic regression was used to compare the 2 cohorts while adjusting for potential confounders.

The selective and prophylactic cohorts consisted of 258 and 330 patients, respectively. Unadjusted analysis showed that the prophylactic group had a significantly lower rate of ureterovesical complications than did the selective group (2.12% vs 6.20%; odds ratio, 0.33; P = .01). After adjustment for differences in sex and donor type, the prophylactic group still had a lower risk for ureterovesical complications (odds ratio, 0.30; P = .009). Rates of urinary tract infections and forgotten stents did not differ significantly between the 2 groups.

Prophylactic stenting is associated with a significantly lower rate of ureterovesical complications than is selective stenting.

Understanding the experience of caring for an adult with a left-ventricular assist device as a destination therapy (LVAD-DT) remains in its infancy.

A hermeneutic-phenomenological inquiry guided by van Manen's methods was used to explore the LVAD-DT family caregiving experience.

Seven family caregivers (1 man and 6 women) 50 to 74 years old who cared for an adult with an LVAD-DT in home settings. Recruitment and data collection occurred in an outpatient mechanical circulatory support center in the Midwest.

Data were collected by means of face-to-face interviews using open-ended questions and 1 follow-up interview. Interviews were audio recorded and transcribed verbatim. Thematic analysis consisted of writing, rewriting, and reflecting across participants' data, which produced themes illustrating the experience and meaning of caring for an adult with an LVAD-DT. Themes were consensually validated. Procedures for trustworthiness are described.

Five main themes were identified from participants' experiences: (1) advanced heart failure is a life-changing event, (2) self-doubt about LVAD caregiving improves over time, (3) lifestyle adjustments come with time, (4) persistent worry and stress, and (5) caregiving is not a burden—it's a part of life. These main themes were elucidated by 8 subthemes in which participants described a process of adjustment despite persistent worry and stress and eventually accepted caregiving as part of their lives. Future studies are needed to explore caregiver burden, adaptation, and the effects of caregiving outcomes, such as emotional and physical health and overall quality of life.

Women of reproductive age account for more than one-third of all solid-organ transplant recipients and are advised against becoming pregnant for 1 to 2 years after their surgeries. The risks posed to the woman, the transplanted organ, and the fetus underscore the importance of systems to ensure that patients receive counseling on family planning, including return to fertility, contraceptive use, and when pregnancy can be safely considered, and highly effective methods of contraception.

To investigate use of contraceptives among women after solid-organ transplant and to identify opportunities to improve care.

A cross-sectional survey study.

An urban academic medical center.

Women 18 to 50 years old who have received a kidney, pancreas, and/or liver transplant within the past 1 to 24 months.

Participants completed self-administered questionnaires regarding their menstrual pattern, pregnancy history, contraceptive use before and after transplant, and counseling on family planning issues.

Contraceptive use.

The most common contraceptive method used in both the year preceding transplant and the year after transplant was condoms. Participants desired more counseling on highly effective contraceptive methods, such as intrauterine devices. Participants would like to receive contraceptive counseling from an obstetrician/gynecologist or transplant care team provider.

Female recipients of solid-organ transplants want more counseling on highly effective methods of contraception.

Patients with chronic renal failure have a high prevalence of coronary artery disease and cardiovascular death. The mortality and the morbidity rates of cardiac surgery are particularly high in these patients with end-stage renal disease. Performing cardiac surgery and kidney transplant in the same session can reduce these complications in the early postoperative period by normalizing renal function.

To compare the mortality and morbidity rates between patients who had undergone cardiac surgery and kidney transplant separately and patients who had combined surgeries.

This retrospective study consisted of 75 patients. One group of 60 patients underwent cardiac surgery and kidney transplant in separate sessions, and the other group of 15 patients had combined surgeries in the same session, between March 2008 and September 2012.

Patients who had combined surgeries achieved fluid electrolytic balance more easily, had shorter extubation times, used less blood and blood products, and had fewer major complications. The patients recovered faster and thus had shorter stays in the intensive care unit and hospital. This combined surgical approach allows normalized kidney function in patients with end-stage renal disease, so mortality and morbidity in the early postoperative period could be significantly reduced.

For adults with end-stage kidney disease, live donor kidney transplant (LDKT) has better outcomes than long-term dialysis and deceased donor kidney transplant. However, black patients receive LDKT at a much lower rate than adults of any other race or ethnicity.

To examine the LDKT readiness stage of black patients on the transplant waiting list and its association with LDKT knowledge, concerns, and willingness.

Cross-sectional analysis of baseline data from a randomized controlled trial to improve knowledge and reduce concerns about LDKT.

One hundred fifty-two black patients on the kidney transplant waiting list at a single transplant center in the northeastern United States.

LDKT readiness stage, knowledge, concerns, and willingness to talk to others about living donation.

Sixty percent of patients were not considering or not yet ready to pursue LDKT, and only 11% had taken action to talk to family members or friends about the possibility of living kidney donation. Patients in later stages of LDKT readiness (ie, who had talked to others about donation or were preparing to do so) had significantly more knowledge (P < .001), fewer concerns (P= .002), and more willingness (P= .001) to talk to others about living donation than those in earlier readiness stages.

The large percentage of black patients who are in the earlier stages of LDKT readiness may account for the low rate of LDKT in this patient population at our transplant center. Innovative and tailored LDKT educational strategies for black patients are needed to help reduce racial disparities in LDKT.

Despite numerous benefits of live donor kidney transplant (LDKT), patient-level barriers often prevent African Americans from considering LDKT. Educational interventions designed to address patient-level barriers may increase willingness among African American patients with end-stage renal disease to explore LDKT as a treatment option.

To assess the effectiveness of a culturally sensitive educational intervention called Living ACTS (About Choices in Transplantation and Sharing) that was designed to address patient-level barriers to LDKT among African American patients with end-stage renal disease.

Patients were randomized to intervention (n = 136) or control (n=132) groups. They completed baseline measures and then viewed either the Living ACTS or control video. Both groups then completed an immediate follow-up measure and a 6-month assessment administered via telephone.

Self-reported knowledge about LDKT, willingness to talk to the patient's family about LDKT, and perceived benefits of LDKT were measured at 3 time points.

At 6-month follow-up, intervention participants demonstrated a significantly greater increase in knowledge of LDKT than control participants (F_2,229 = 3.08, P = .05). Intervention participants expressed greater willingness to talk to patients' families about LDKT than did control participants from baseline through 6-month follow-up (F_1,230 = 7.11, P= .008). Finally, at immediate follow-up, intervention participants reported greater endorsement of the benefits of LDKT than did control participants (F_2,223 = 14.27, P < .001); however, this effect had disappeared by the 6-month follow-up.

Living ACTS is effective at increasing and maintaining knowledge about LDKT among African American patients with end-stage renal disease who are considering transplant.

Kidney paired donation chains are initiated by nondirected donors and propagated by donors within the chain of transplants, or chain donors.

To compare psychosocial and functional outcomes, and to test coercion, of chain donors in paired exchange versus traditional directed donors who have an established relationship with the recipient.

Thirty chain donors from a transplant center who were part of the National Kidney Registry paired exchange program were compared with 34 traditional donors who donated around the same time. Participants completed online surveys: the post-donation section of the Living Donor Expectancies Questionnaire was used to assess psychosocial and functional outcomes 1 to 6 years after donation. A survey to assess coercion was used as well.

Chain donors and traditional donors were similar in terms of sex, race, age, and time after donation. The 2 groups had similar altruistic motives in donating their kidney, and both types of donors mentioned psychological benefits. No differences were found on questions regarding psychosocial outcomes save for the “quid pro quo scale” (P = .01), which suggested that the traditional donors felt more that the recipients are indebted to them. The 2 groups did not differ significantly in the coercion measure. Pressure to donate and stress of donation were not greater in chain donors than traditional donors (P = .60).

Kidney donors in kidney paired donation chains do as well as traditional donors psychosocially without any increased tendency toward experiencing coercion.

To minimize impaired psychosocial outcomes among living liver donors, it may be useful to obtain their views about being a donor with respect to their specific backgrounds.

To describe the perceptions of living liver donors with respect to transplant surgery and to determine whether any differences in perceptions were related to the recipient's age or prognosis.

In total, 240 living liver donors (mean age, 44.4 years) openly and freely described their views on transplant.

Content analysis of the descriptions revealed 4 categories: grateful for the benefits of living donor liver transplant (n = 143, 59.6%), facing the limitations of living liver transplant (n = 125, 52.1%), donor stress (n= 105, 43.8%), and crucial preoperative period (n = 75, 31.2%). The frequency of descriptions of gratitude for the benefits of transplant differed significantly between adult-to-adult and adult-to-child transplants: donors to children (ie, recipients <18 years old) were more grateful than were donors to adults (ie, recipients ≥18 years old). In addition, descriptions of gratitude differed significantly depending on the recipient's prognosis: donors with recipients who survived were more grateful and experienced fewer difficulties than did donors with recipients who died.

In general, living liver donors were satisfied with transplant surgery but experienced living donor liver transplant as a burden, which was affected by the transplant outcome and the age of the recipient.