RESUMEN
A lack of research exploring post-transplant process optimization to reduce readmissions and increasing readmission rates at our center from 2009 to 2013 led to this study, aimed at assessing the effect of patient and process factors on 30-d readmission rates after kidney transplantation. This was a retrospective case-control study in adult kidney transplant recipients. Univariate and multivariate analyses were utilized to assess patient and process determinants of 30-d readmissions. 384 patients were included; 30-d readmissions were significantly associated with graft loss and death (p = 0.001). Diabetes (p = 0.049), pharmacist identification of poor understanding or adherence, and prolonged time on hemodialysis prior to transplant were associated with an increased risk of 30-d readmissions. After controlling for risk factors, readmission rates were only independently predicted by pharmacist identification of patient lack of understanding or adherence regarding post-transplant medications and dialysis exposure for more than three yr (OR 2.3, 95% CI 1.10-4.71, p = 0.026 and OR 2.1, 95% CI 1.22, 3.70, respectively), both of which were significantly modified by history of diabetes. Thirty-d readmissions are attributable to both patient and process-level factors. These data suggest that a lack of post-transplant medication knowledge in high-risk patients drives early hospital readmission.
Asunto(s)
Trasplante de Riñón , Cumplimiento de la Medicación , Evaluación del Resultado de la Atención al Paciente , Readmisión del Paciente/tendencias , Complicaciones Posoperatorias/prevención & control , Estudios de Casos y Controles , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Tiempo de Internación/tendencias , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Estudios Retrospectivos , Factores de Riesgo , Estados Unidos/epidemiologíaRESUMEN
Pregnancy after thoracic organ transplantation is feasible for select individuals but requires multidisciplinary subspecialty care. Key components for a successful pregnancy after lung or heart transplantation include preconception and contraceptive planning, thorough risk stratification, optimization of maternal comorbidities and fetal health through careful monitoring, and open communication with shared decision-making. The goal of this consensus statement is to summarize the current evidence and provide guidance surrounding preconception counseling, patient risk assessment, medical management, maternal and fetal outcomes, obstetric management, and pharmacologic considerations.
Asunto(s)
Consejo , Salud Reproductiva , Embarazo , Femenino , Humanos , ConsensoRESUMEN
Solid organ transplantation (SOT) is a lifesaving procedure for those with end-stage kidney, liver, heart, lung, and intestinal diseases, including females of childbearing age who wish to proceed with pregnancy following transplantation. While there is clear risk associated with use of mycophenolate during pregnancy, the risks associated with use of other immunosuppressant agents are less well understood, and the timing of use in pregnancy may be pertinent when considering the risk versus benefit for individual patients. In addition to overall fetal outcomes, including gestational age, birth weight, and mortality, this review summarizes published literature on additional complications that have been examined in association with maternal use during pregnancy and postpartum while breastfeeding. Compared with non-transplant pregnancies, pregnancies in transplant recipients are associated with lower birth weight and earlier gestational age. Effects associated with particular immunosuppressant agents in the infant include renal dysfunction from calcineurin inhibitors, myelosuppression from azathioprine, and decreased circulating immune cells with several agents. However, these effects are noted to primarily be transient, though the decrease in immune cells may predispose the infant to increased infectious complications in the first year of life. Utilizing relative infant dose estimations, nearly all commonly utilized immunosuppressants are likely safe during breastfeeding given the limited exposure to the infant.
Asunto(s)
Trasplante de Riñón , Complicaciones del Embarazo , Peso al Nacer , Lactancia Materna , Niño , Femenino , Humanos , Terapia de Inmunosupresión/efectos adversos , Inmunosupresores/efectos adversos , Trasplante de Riñón/efectos adversos , Lactancia , Embarazo , Resultado del Embarazo , Receptores de TrasplantesRESUMEN
STUDY OBJECTIVE: Induction immunosuppression significantly improves graft outcomes after kidney transplantation, but protocols vary among transplant centers due to the lack of data identifying an optimal induction agent. The objective of this study was to assess the effectiveness of an evidence-based protocol change in induction therapy in adult kidney transplant recipients. DESIGN: Retrospective cohort study. SETTING: Large tertiary care academic medical center. PATIENTS: A total of 349 patients transplanted between August 2011 and December 2013 were included in the study. A protocol revision in 2012 reserved the use of lymphocyte-depleting induction therapy to a select group of traditionally high-risk patients based on the findings of a previous randomized controlled trial performed at this center. MEASUREMENTS AND MAIN RESULTS: The primary outcome was biopsy-proved acute rejection and graft loss. The use of nondepleting induction therapy increased significantly after the protocol revision, with no significant differences in rejection or infection rates identified between protocols. When comparing graft survival between the protocol cohorts, there was no significant difference. A cost-minimization analysis indicated that the revised protocol was associated with considerable medication cost savings. CONCLUSION: A protocol targeting the use of lymphocyte-depleting induction to a select group of high-risk recipients appears to have equivalent efficacy and safety and is less costly compared with a more traditional induction protocol.
Asunto(s)
Medicina Basada en la Evidencia/métodos , Rechazo de Injerto/tratamiento farmacológico , Inmunosupresores/uso terapéutico , Quimioterapia de Inducción/métodos , Trasplante de Riñón , Receptores de Trasplantes , Adulto , Protocolos Clínicos , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Rechazo de Injerto/diagnóstico , Humanos , Trasplante de Riñón/efectos adversos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Females of childbearing age represent a large population of solid organ transplant recipients. With fertility commonly restored after transplantation, the possibility of pregnancy becomes a reality for many patients. Since the first published report of a successful pregnancy after solid organ transplantation in 1963, the number of pregnancies reported for female organ recipients has continued to increase. Despite this, information on the management of immunosuppression during pregnancy is limited, and a summary of these data is lacking in the literature. In addition to the many pharmacotherapeutic challenges in this unique patient population, physiologic changes in the peripartum period significantly affect the pharmacokinetics and pharmacodynamics of commonly used immunosuppressive agents. These changes, as well as the adverse effects and safety concerns of medications, must all be taken in to consideration to optimize outcomes for both mother and baby. In this review, we provide clinicians caring for female solid organ transplant recipients who wish to become pregnant or who are currently pregnant with a comprehensive review of maternal and fetal risks of pregnancy after transplantation. In addition, pharmacokinetic and pharmacodynamic changes of pregnancy will be discussed, and a summary of data regarding optimal immunosuppression management during pregnancy will be presented.
Asunto(s)
Feto/efectos de los fármacos , Inmunosupresores/efectos adversos , Trasplante de Órganos , Complicaciones del Embarazo , Femenino , Supervivencia de Injerto , Humanos , Embarazo/fisiología , Resultado del EmbarazoRESUMEN
OBJECTIVE: To implement and assess the impact of a virtual patient pilot program on pharmacy students' clinical competence skills. DESIGN: Pharmacy students completed interactive software-based patient case scenarios embedded with drug-therapy problems as part of a course requirement at the end of their third year. ASSESSMENT: Assessments included drug-therapy problem competency achievement, performance on a pretest and posttest, and pilot evaluation survey instrument. Significant improvements in students' posttest scores demonstrated advancement of clinical skills involving drug-therapy problem solving. Students agreed that completing the pilot program improved their chronic disease management skills and the program summarized the course series well. CONCLUSION: Using virtual patient technology allowed for assessment of student competencies and improved learning outcomes.