Progress in Transplantation最新文献

Due to increased risk of myalgia and rhabdomyolysis associated with the use of simvastatin with cyclosporine, use of high-intensity 3-hydroxy-3-methylglutaryl Coenzyme A reductase inhibitors (statins) is often avoided in transplant recipients. Aim: This program evaluation aimed to determine the safety of high-intensity statins in liver and kidney transplant recipients taking tacrolimus. Design: All liver and kidney transplant recipients who filled prescriptions for tacrolimus and any statin except for simvastatin between June 15, 2020 and July 22, 2022 were screened for inclusion. High-intensity was defined as atorvastatin 40 or 80 mg, or rosuvastatin 20 or 40 mg. The primary outcome was a composite of statin-related myalgia, statin-related rhabdomyolysis, and creatine kinase above the upper limit of normal. Secondary outcomes included liver function tests above 3 times the upper limit of normal, statin discontinuation, and statin dose decrease and associated reason. Results: A total of 178 recipients were included, with 100 receiving low-to-moderate-intensity statins and 78 receiving high-intensity statins. There were no differences between groups for statin-related myalgia, and no reported cases of statin-related rhabdomyolysis in either group. Low to moderate intensity statin use was associated with an increased rate of liver function test elevation (26% vs 11.5%, P = .014) occurring a median of 306 days (interquartile range [IQR] 134-725) post-statin initiation. Conclusion: In liver and kidney transplant recipients receiving tacrolimus, the use of high-intensity statins was not associated with an increased risk of myalgia, rhabdomyolysis, or elevated creatinine kinase when compared with low-to-moderate-intensity statin use.

The transplant selection process for solid organ recipients relies on committee review and is susceptible to human nature and bias. The current model of selection committees has been under-examined and untested. Few studies exist on transplant selection committees. Barriers to quality decision-making have been studied in other industries. Lessons learned in other industries were explored and how they may be applied to a transplant selection committee. These include appointing an ethical representative or an advocate (pro) and dissenter (against) for discussion, adopting an ideal committee size/composition, and reviewing previous committee decisions (post-mortem). The transplant selection committee can function beyond a singular decision and be an opportunity to identify gaps in patients' treatment plans and available resources. Looking forward, a transplant selection committee that is more consistent, equitable, and protocolized can reduce bias, moral burden, and missed listings for our patients.

IntroductionPostoperative atrial fibrillation is an arrhythmia that may complicate postsurgical care in kidney transplant recipients and is associated with longer hospitalizations, postsurgical complications, and increased in-hospital mortality. Pathophysiology is not well understood but is thought to be multifactorial. Iatrogenic hypervolemia may contribute to the incidence of postoperative atrial fibrillation. Project AimsThe program evaluation aim was to evaluate the effects of furosemide concentration on reducing volume overload, and subsequently postoperative atrial fibrillation incidence. DesignThis was a single-center, retrospective, cohort study that analyzed kidney transplant recipients during index hospitalization. Recipients receiving furosemide infusions of 500 mg/50 mL between June 2022 and May 2023 were considered the concentrated group and recipients receiving infusions of 500 mg/250 mL between January 2013 and December 2017 were the dilute group. ResultsThere was no difference identified in atrial fibrillation rates when using concentrated versus dilute furosemide infusions (7.7% vs 12.4%; P = .101). When excluding those with immediate graft function, there was a lower incidence in the concentrated group (9.3% vs 22.0%, P = .031) compared to slow/delayed graft function. Recipients in the concentrated infusion group had higher rates of high (11.7% vs 35.1%) and very high (3.0% vs 14.9%) cardiovascular risk (P < .001). Recipients receiving concentrated infusions had improvement in net fluid balance (0.4 L vs 1.4 L; P < .001) with higher furosemide exposure (2.3 g vs 1.4 g; P < .001). ConclusionsPostoperative atrial fibrillation rates were similar between groups, Recipients with slow/delayed graft function had lower rates of postoperative atrial fibrillation with concentrated furosemide.

Introduction: Sleep is essential for maintaining optimal physical and mental health as it supports crucial functions such as cognition, immune system regulation, and overall well-being. A growing emphasis on the importance of sleep warrants an investigation of sleep quality after lung transplantation. Research Question: What is the overall prevalence, nature, and severity of patient-reported disrupted sleep quality after lung transplantation using the Pittsburgh Sleep Quality Index (PSQI)? Design: This study employed a single-site, exploratory, cross-sectional descriptive design involving lung transplant recipients who completed an anonymous survey. Sleep quality was assessed using the PSQI scale. Additionally, participants provided self-reported data on demographic and transplant-related variables. Results: The response rate was 38.4% (61/158) and 64% of the respondents (39/61) demonstrated PSQI >5 with a mean PSQI score of 8.07 (SD = 4.5), suggestive of poor sleep quality. Lung transplant recipients reported difficulties across all components of sleep quality with more challenges in the categories of sleep duration, sleep latency, sleep efficiency, and the use of sleep medications. Conclusion: The prevalence of poor subjective sleep quality among lung transplant recipients highlighted the importance of continued investigation into this phenomenon. Further research employing standardized measures, larger sample sizes, and longitudinal study designs is warranted to enhance understanding of poor sleep post-lung transplant. Such endeavors are crucial for informing the development of effective assessment strategies and interventions aimed at improving sleep outcomes in patients after lung transplantation.

Introduction: Posttransplant sleep disturbances may influence recovery, immunosuppressive adherence, and graft outcomes. This study examined sleep disruption in acute renal transplant recipients and its relationship with medication comprehension and hospital stressors. Methods/Approach: A mixed-methods, pilot prospective cohort study was conducted at a metropolitan hospital in Australia. Consecutive renal transplant patients were recruited. Perioperative sleep patterns were assessed using the American Academy of Sleep Medicine's sleep diary. The Kidney Transplant Understanding Tool evaluated medication comprehension. Qualitative data from semistructured interviews were analysed using inductive content analysis. Univariate linear regression assessed associations between sleep and perioperative outcomes (P ≤ .05). Findings: Ten recipients were recruited. Recipients averaged 5.2 hours of sleep per night with frequent disruptions. Sleep ranged from 0 to 10 hours per night, with the longest sleepless period being 41 hours. An inverse correlation was observed between sleep duration and medication comprehension scores(β=-8.736, P = .0232), suggesting recipients with less sleep had better medication comprehension. Qualitative analysis identified sleep disruptions due to hospital practices, environmental factors, transplant-related stress, and medication side effects. Conclusion: Perioperative sleep disturbances were multifactorial, influenced by hospital and procedural factors. The paradoxical association between reduced sleep and increased medication comprehension highlights a complex interplay between stress, sleep, and cognitive engagement. This pilot study suggested that addressing sleep disturbances and incorporating culturally sensitive education may enhance perioperative care. However, further research is needed to validate these findings in larger cohorts.

IntroductionCharacteristics and the impact of frailty on adult solid organ transplant recipients have not been clearly described. The purpose of this integrative review was to identify characteristics of frailty and associations between frailty and patient mortality and graft failure in adult solid organ transplant recipients.MethodsAn integrative literature review was performed using Cooper's integrative methodology. PubMed, Excerpta Medica, and the Cumulative Index of Nursing and Allied Health Literature databases were searched using the terms frailty and transplant. Inclusion criteria were primary research reports, written in English, focusing on adult solid organ transplant recipients, and including graft or patient survival outcomes.ResultsThe review included 35 articles, were largely retrospective, and published between 2015 and 2023 in 11 different countries. Most studies were single-center studies that were not theory-based, and liver transplant recipients were highly represented. Males outnumbered females in the majority of studies and White race was represented in half of the studies. Most studies used one strategy to measure frailty, and modified versions of the Physical Frailty Phenotype were the measurement used most often. Of the 35 articles that investigated the association of frailty with patient mortality, 44 measures were used, and of those, 32 showed a significant association. For graft failure, of the 10 studies included, half showed a significant association between frailty and graft failure.ConclusionThis integrative review offers insights into the characteristics and the association between frailty, patient mortality, and graft failure.

Introduction: Research shows that donor families report feeling abandoned, lacking social support, and receiving insufficient aftercare services. To meet the needs of these families, Taylor's Gift Foundation developed a free, virtual grief support program that pairs participating donor family members with Caring Guides trained in assertive community engagement and offers peer-facilitated support groups. Project Aim: The aim was to assess participant experiences with Taylor's Gift Foundation grief support program to understand its impact on grief symptoms, donor family access to grief support, and perceived social support. Design: Researchers conducted a qualitative evaluation using semi-structured interviews with 21 program participants. Results were analyzed using rapid qualitative analysis and descriptive statistics. Results: Eighteen (86%) participants worked with Caring Guides, 12 (57%) attended an average of 7 support groups, and 8 (39%) worked with Caring Guides and attended support groups. Eleven (52%) program participants reported difficulties accessing mental health services. Most program participants (86%) reported a decrease in grief intensity since enrolling in the program. Conclusion: Effective aftercare services were critical in helping donor families cope with, and adapt to, their loss. The Taylor's Gift Foundation grief support program helped donor family members access otherwise inaccessible grief support services and provided a valuable means of social support.

Introduction: Adverse effects from antimetabolites often lead to therapy adjustments; older patients may be more susceptible to these effects. Project Aims: Compare the intolerance of antimetabolites between older and younger lung transplant recipients. Design: A single-center, retrospective analysis of adult lung transplant recipients transplanted between January 1, 2019 and October 31, 2021 was conducted. Patients were stratified by age at the time of transplant (≥60 or <60 years) and assessed for the first year posttransplant. The primary outcome was the incidence of antimetabolite intolerance (defined as dose adjustment, agent/formulation change, or holding/discontinuation of agent). Secondary outcomes included reason for intolerance, safety (infection and leukopenia), and efficacy (rejection and patient/graft survival). Results: One hundred and nine recipients were included; 54 in the older (≥60 years) and 55 in the younger (<60 years) cohort. Most were initiated on azathioprine (74%) posttransplant. Antimetabolite intolerance occurred in 61% of older and 53% of younger recipients (P = 0.377). The most common reasons for intolerance were leukopenia followed by gastrointestinal side effects. Biopsy-proven acute rejection occurred more often in the older cohort (39% vs 18%, P = 0.017); this no longer remained significant when controlling for induction, indication, transplant type, gender, and antimetabolite intolerance (OR 0.36, 95% CI 0.11 to 1.15). There was no difference in the incidence of leukopenia, bacterial infection, or graft/patient survival within 1 year posttransplant. Conclusion: Antimetabolite intolerance between older and younger lung transplant recipients was similar. Most required modification to the initial antimetabolite regimen due to leukopenia and gastrointestinal side effects.

Introduction: While survival following liver transplantation has improved over the past 3 decades, few studies have examined the changes over time in hospital length of stay (LOS), a surrogate for healthcare expenditure and an important short-term outcome measure.

Research question: The purpose of this study was to compare post-transplantation LOS over the last 3 decades.

Design: A cross-sectional analysis of 150 603 adult liver transplant recipients between September 1987 and July 2021 from the UNOS database was conducted. The patients were placed into 3 eras (1987-1989, 1990-1999, and 2000-2021) based on a Join point regression analysis of significant time points of change in LOS trends. Risk factors that were significant in univariate analysis (P < .05) were included in the multivariable Cox regression analysis, which controlled for 29 donor/recipient characteristics.

Results: Among adult patients, the average LOS following liver transplantation changed from 51.5 days in 1987 to 16.3 days in 2021, with a relatively steeper decline prior to 2000. On multivariable Cox regression, patients in both the 1987-1989 cohort (hazard ratio [HR]: 0.54, 95% confidence interval [CI]: 0.52-0.57) and the 1990-1999 cohort (HR: 0.77, CI: 0.76-0.78) had significantly prolonged lengths of stay (HR < 1 associated with later hospital discharge) compared to the 2000-2021 cohort.

Conclusions: This analysis found that mean LOS decreased over time in adult liver transplant recipients, even after controlling for donor and recipient-level factors. Future studies are needed to elucidate root cause factors for this decline in LOS over time.