Leukocyte transcriptome indicators of development of infection in kidney transplant recipients.

After kidney transplantation, infection and death are important clinical complications, especially for the growing numbers of older patients with limited resilience to withstand adverse events. Evaluation of changes in gene expression in immune cells can reveal the underlying mechanisms behind vulnerability to infection. A cohort of 60 kidney transplant recipients was evaluated. Gene expression in peripheral blood mononuclear cells 3 months after kidney transplantation was analyzed to compare differences between patients with infection and those who were infection-free in the first-year post-transplant. Pro-inflammatory genes such as IL1B, CCL4, and TNF were found to be downregulated in post-transplant PBMC from patients who developed infection. In contrast, genes involved in metabolism, HLA genes, and transcripts involved in type I interferon innate antiviral responses were found to be upregulated. Promoter-based bioinformatic analyses implicated increased activity of interferon regulatory factors, erythroid nuclear factor (E2), and CCAAT-enhancer-binding protein (C/EBP) in patients who developed infections. Differential patterns of gene expression were observed in patients who developed infection after kidney transplantation, with patterns distinct from changes associated with patient age, suggesting possible mechanisms behind vulnerability to infection. Assessment of gene expression in blood may offer an approach for patient risk stratification and monitoring after transplantation.

Health Disparities in Kidney Transplantation for African Americans.

BACKGROUND: The persistent challenges of bridging healthcare disparities for African Americans (AAs) in need of kidney transplantation continue to be unresolved at the national level. This healthcare disparity is multifactorial: stemming from limited kidney donors suitable for AAs; inconsistent care coordination and suboptimal risk factor control; social determinants, low socioeconomic status, reduced access to care; and mistrust of clinicians and the healthcare system. SUMMARY: There are numerous opportunities to significantly lessen the disparities in kidney transplantation for AAs through the following measures: the adoption of new care and patient engagement models that include education, enhanced practice-level cultural sensitivity, and timely referral as well as increased research on the impact of the environment on genetic risk, and implementation of new transplantation-related policies. Key Messages: This systematic review describes pretransplant concerns related to access to kidney transplantation, posttransplant complications, and policy interventions to address the challenging issues associated with kidney transplantation in AAs.

Simultaneous liver-kidney transplantation or liver transplantation alone for patients in need of liver transplantation with renal dysfunction.

PURPOSE OF REVIEW: There have been no well defined guidelines to determine whether a kidney transplant should be offered to liver transplant candidates who have chronic kidney disease (CKD) or prolonged acute kidney injury while awaiting a liver transplant. This article provides a review of current literature on risk factors for CKD progression after liver transplantation alone (LTA) in patients with pretransplant renal dysfunction and the utility of cystatin C (Cyst C) to assess renal function in cirrhotic patients. Studies evaluating risk factors for transplant futility are also discussed. Based on available literature and existing consensus guidelines, a proposed algorithm for simultaneous liver-kidney transplantation (SLKT) or LTA is formulated. RECENT FINDINGS: In LTA recipients with pretransplant renal dysfunction, diabetes mellitus and type 2 hepatorenal syndrome are associated with CKD progression posttransplant. Coexisting diabetes and stages 3-4 CKD increase end-stage renal disease risk. Cyst C may be a better marker of renal function in cirrhotics. In LTA recipients, very high MELD scores and the concomitant presence of multiple comorbidities increase liver transplant futility risk. Similar studies in SLKT recipients are lacking. SUMMARY: Pretransplant diabetes status should be incorporated into future guidelines for SLKT, whereas simultaneous kidney transplantation should be deferred in highest acuity SLKT candidates with high kidney transplant futility risk. Cyst C-based equations may allow clinicians to better select the most appropriate candidates for SLKT or LTA. Further studies are needed.

Correction of hyponatremia and osmotic demyelinating syndrome: have we neglected to think intracellularly?

BACKGROUND: Osmotic demyelination syndrome (ODS) is a complication generally associated with overly rapid correction of hyponatremia. Traditionally, nephrologists have been trained to focus solely on limiting the correction rate. However, there is accumulating evidence to suggest that the prevention of ODS is beyond achieving slow correction rates. METHODS: We (1) reviewed the literature for glial intracellular protective alterations during hyperosmolar stress, a state presumed equivalent to the rapid correction of hyponatremia, and (2) analyzed all available hyponatremia-associated ODS cases from PubMed for possible contributing factors including correction rates and concurrent metabolic disturbances involving hypokalemia, hypophosphatemia, hypomagnesemia, and/or hypoglycemia. RESULTS: In response to acute hyperosmolar stress, glial cells undergo immediate extracellular free water shift, followed by active intracellular Na(+), K(+) and amino acid uptake, and eventual idiogenic osmoles synthesis. At minimum, protective mechanisms require K(+), Mg(2+), phosphate, amino acids, and glucose. There were 158 cases of hyponatremia-associated ODS where both correction rates and other metabolic factors were documented. Compared with the rapid correction group (>0.5 mmol/L/h), the slow correction group (≤0.5 mmol/L/h) had a greater number of cases with concurrent hypokalemia (49.4 vs. 33.3 %, p = 0.04), and a greater number of cases with any concurrent metabolic derangements (55.8 vs. 38.3 %, p = 0.03). CONCLUSION: Glial cell minimizes volume changes and injury in response to hyperosmolar stress via mobilization and/or utilization of various electrolytes and metabolic factors. The prevention of ODS likely requires both minimization of correction rate and optimization of intracellular response during the correction phase when a sufficient supply of various factors is necessary.

Changes in the small bowel of symptomatic kidney transplant recipients converted from mycophenolate mofetil to enteric-coated mycophenolate sodium.

BACKGROUND/AIMS: Gastrointestinal (GI) symptoms in renal transplant recipients may be caused due to mycophenolic acid (MPA) toxicity. Using small bowel capsule endoscopy (SBCE) we examined the impact of conversion from Mycophenolate Mofetil (MMF) to enteric-coated formulation of Mycophenolate Sodium (EC-MPS) given to treat GI mucosal lesions. METHODS: Adult kidney-only recipients at least 30 days after transplant, presenting with GI symptoms while receiving MMF completed a Gastrointestinal Symptom Rating Scale (GSRS) questionnaire, underwent SBCE, and had MMF substituted by EC-MPS. After 30 days, GSRS and SBCE were repeated and findings were compared to baseline values. Patients who were still on EC-MPS 6-24 months post-conversion were contacted for completing a follow-up GSRS questionnaire and SBCE. RESULTS: Eighteen out of 23 subjects completed the first part of the study. Subjects' median ages and post-transplant time were 47.5 years old and 4.5 months, respectively. Tacrolimus, MMF and prednisone was the main regimen (94%), with a median MMF dose of 750 mg BID. The average baseline GSRS was 2.99 ± 0.81; it significantly decreased to 2.19 ± 0.8 at 30 days post-conversion. At baseline, 50 had gastric and 89% had small bowel lesions. At 30 days, 29 and 62% of the SBCE were still showing gastric and small bowel lesions, respectively. Of 5 patients in the study extension, 4 had abnormal SBCE findings but have been reporting improvement in their symptoms. CONCLUSION: Stomach and small bowel mucosal lesions are common in kidney recipients with GI symptoms when treated with MMF. Conversion to EC-MPS for 30 days significantly alleviated the GI symptoms; however, no evident correlation with SBCE findings was found.

BK virus infection following kidney transplantation: an overview of risk factors, screening strategies, and therapeutic interventions.

PURPOSE OF REVIEW: In recipients of kidney transplants, the emergence of BK virus (BKV)-associated clinical syndromes, such as viruria, viremia, and BK nephropathy, coincided with the advent of potent immunosuppressive therapy. There is currently no standardized protocol for the management of BK viruria or viremia, or established BK nephropathy. Suggested risk factors for BKV replication and a literature overview on various treatment strategies for BKV-associated clinical syndromes are presented, followed by the authors' proposed approach for screening, monitoring, and treatment of post-transplant BKV infection. RECENT FINDINGS: BKV infection can occur under all combinations of immunosuppressive therapy. Although both humoral and cellular immunity may be essential, BKV-specific T-cell immunity appears to play a pivotal role in controlling BKV replication. Monitoring BKV-specific immune response might prove useful in guiding therapeutic intervention. The beneficial effects of antiviral agents remain unclear. Development of T-cell or antibody-based vaccines against BKV is a subject of future research. SUMMARY: In the absence of conclusive evidence that any particular immunosuppressive agent has a specific influence over another on BKV infection risk and the unclear benefit of antiviral agents, intensive monitoring of serum BKV using PCR and immunological containment of BKV replication should remain the mainstay of therapy. The routine recommendations of antiviral agents in the treatment of BKV-associated clinical syndromes await results of large prospective randomized trials.

Improved survival among sickle cell kidney transplant recipients in the recent era.

BACKGROUND: Studies from older cohorts of kidney recipients have observed that recipients with sickle cell disease (SCD) have lower patient survival compared with age- and race-matched controls. We examined whether survival has improved among SCD recipients in the current era. METHODS: Using Organ Procurement and Transplantation Network/United Network for Organ Sharing data, all black/African-American kidney recipients were stratified according to transplant year into an early (1988-99) and recent era (2000-11). Patient and allograft survival among SCD recipients and those with other diagnoses were compared (early era: SCD n = 67, others n = 20 694; recent era: SCD n = 106, others n = 34 428). A secondary-matched cohort analysis compared patient and allograft survival between SCD recipients matched to recipients with other diagnoses based on recipient and donor age, gender and donor type (deceased versus living). RESULTS: Patient survival at 6 years was lower among SCD recipients in the early era compared with other diagnoses (55.7 versus 78.0%; P < 0.001). Six-year patient survival among sickle cell recipients improved in the recent era (69.8%; P versus early era = 0.04), although still trended toward lower survival compared with other diagnoses (80.0%; P = 0.07). Multivariate Cox proportional hazard models revealed an increased mortality risk with SCD in both eras [early: hazard ratio (HR) = 3.12; 95% confidence interval (CI): 2.15-4.54; recent: HR: 2.03; 95% CI: 1.31-3.16]. Patient survival among matched SCD recipients in the recent era was comparable to diabetic recipients (SCD: 73.1%, diabetes: 74.1%; P = 0.44). CONCLUSIONS: Patient survival has improved among contemporary sickle cell recipients compared with an earlier cohort and is comparable to a matched cohort of diabetic kidney recipients. Appropriately selected SCD patients may receive kidney transplants with reasonable survival outcome.

Kidney transplantation in the obese transplant candidates: to transplant or not to transplant?

The prevalence of obesity (body mass index ≥30 kg/m(2)) at the time of transplantation among kidney transplant recipients in the United States has doubled between 1987 and 2001 and continues to increase inexorably. Single-center and large registry studies in kidney transplant recipients demonstrated that high body mass index (BMI) at transplant is associated with increased risk of wound and surgical site infections, delayed graft function (DGF), acute rejection episodes, and graft loss, among others. Hence, in many centers, obese transplant candidates are denied a transplant based on their body mass index (BMI) alone. The impact of obesity on short- and long-term graft and patient outcomes after kidney transplantation are herein revisited, followed by the authors' proposed approach to evaluate and select obese transplant candidates for a kidney transplant. Suggested interventions to optimize the health of such candidates are also discussed.

Reduction in Maintenance Immunosuppression in Kidney Transplant Recipients With Stable Donor-Derived Cell-Free DNA Measurements: A Case Series.

Personalization of maintenance immunosuppression in kidney transplant recipients has long remained a goal in the transplant community. The recent addition of donor-derived cell-free DNA assays to detect allograft rejection and monitor allograft health may permit for reductions in maintenance immunosuppression in recipients with stable levels. Herein, we described 5 patients with stable donor-derived cell-free DNA levels who underwent reduction in maintenance immunosuppression without precipitation of clinical rejection, proteinuria, or de novo donor specific antibody formation.

Levels and Associated Factors of Clients' Satisfaction Toward Child Immunization at Grassroot Health Care Centers in Ho Chi Minh City, Vietnam.

Purpose: Immunization is the most cost-effective health strategy, contributing significantly to public health interventions for all ages, particularly for children. However, caregivers' satisfaction with immunization systems affects their decisions on immunization for their children. This study evaluated the levels of clients' satisfaction toward child immunization and to identify its associated factors. Methods: A cross-sectional study was conducted at 40 commune health centers (CHCs) in 24 districts in Ho Chi Minh City, Vietnam among 1200 caregivers of children aged under 5 years. Clients who took their children to CHCs for immunization were recruited based on convenience sampling technique and were asked to complete a self-report questionnaire. Satisfaction was measured using the Satisfaction with Immunization Service Questionnaire (SWISQ). Ordinal logistic regression models were fitted to identify factors associated with satisfaction levels. Results: The majority of participants were female (85.5%) with a mean age of 33.3 (standard deviation = 9.0). Approximately 60% of participants reported a moderate (40.2%) or high (17.1%) level of satisfaction. Participants with older children and those who waited for a longer duration had a lower satisfaction level. In contrast, high satisfaction level was found to be positive associated with being reminded by healthcare workers and the condition of follow-up areas, vaccine storage and the immunization process met participant's need. Conclusion: The level of clients' satisfaction toward child immunization at grassroot healthcare centers in Ho Chi Minh City is relatively low, with 40.2% having moderate satisfaction and 17.1% having high satisfaction. Strategies to improve vaccination programs at CHCs are needed, focusing on clients' experiences at CHCs during vaccination sessions. Further studies are also needed to have an in-depth understanding of more factors affecting satisfaction in this population.

Physical Frailty Predicts Outcomes in Patients Undergoing Evaluation for Kidney Transplantation.

INTRODUCTION: An increasing number of older patients are undergoing evaluation for kidney transplantation; however, older patients experience increased rates of complications compared with younger patients, leading to the study of frailty assessments. Although many centers have evaluated the Fried Frailty Phenotype (FFP), less is known about the ability of the Short Performance Physical Battery (SPPB) to predict outcomes. METHODS: Frailty assessment by FFP and SPPB was introduced into routine outpatient evaluation for patients aged 55 years and older referred for transplantation. Transplant rate, length of stay, readmission up to 3 months posttransplant, and death were reviewed. Patients were evaluated in an initial cohort followed by a validation cohort by FFP and SPPB. Multivariate analysis correcting for demographic characteristics was applied. RESULTS: Patient cohorts reflected the racial and ethnic diversity of our population, including approximately 40% Hispanic patients. The first cohort of 514 patients demonstrated a significant association between frailty as measured by SPPB and transplantation (odds ratio [OR], 2.27; 95% CI, 1.38-3.83; p = .002). The second cohort of 1408 patients validated the association between frailty measured by SPPB and transplantation (OR, 2.81; 95% CI, 1.83-4.48; p < .001). In addition, there was a significant association between nonfrail status measured by SPPB and death (OR, 0.16; 95% CI, 0.04-0.62; p = .006). CONCLUSIONS: Frailty assessment is a potentially useful approach for the assessment of transplant candidates. Our real-world study examined the performance of 2 methods of frailty evaluation methods in a diverse population, demonstrating that SPPB but not FFP was predictive of clinical outcomes. Incorporation of frailty assessments into transplant evaluation may improve risk stratification and optimize outcomes for older patients.

The impact of mycophenolate mofetil versus azathioprine as adjunctive therapy to cyclosporine on the rates of renal allograft loss due to glomerular disease recurrence.

BACKGROUND: Given the reported efficacy of mycophenolate mofetil (MMF) in the treatment of glomerular diseases, we question whether MMF can reduce the rate of renal allograft loss due to glomerular disease recurrence compared to azathioprine (AZA) as adjunctive therapy to cyclosporine (CSA)-based immunosuppression. METHODS: This is a retrospective study based on the Organ Procurement and Transplantation Network/United Network for Organ Sharing (OPTN/UNOS) database designed to compare the Kaplan-Meier rates of graft loss due to disease recurrence stratified by primary renal diagnoses between recipients receiving CSA+AZA versus CSA+MMF. Recipients of primary kidney transplants (both deceased donor and living, related and unrelated) renal transplants performed between 1 January 1988 and 31 December 2007 with the primary renal diagnosis of IgA nephropathy (IgAN), membranous glomerulonephropathy (MGN), membranoproliferative glomerulonephropathy (MPGN), lupus nephritis (LN) or focal segmental glomerulosclerosis (FSGS) with a functioning allograft at discharge were included. RESULTS: Seven thousand eight hundred and twenty-six recipients of primary deceased donor kidney transplants (DDKT) [CSA + AZA: IgAN (890), MGN (380), MPGN (193), LN (1324), FSGS (1314) and CSA+MMF: IgAN (855), MGN (614), MPGN (116), LN (715), FSGS (1425)] and 5498 recipients of living donor kidney transplants (LDKT) [CSA+AZA: IgAN (694), MGN (229), MPGN (100), LN (592), FSGS (654) and CSA+MMF: IgAN (1066), MGN (435), MPGN (89), LN (530), FSGS (1109)] were included in the analysis. At 10-year follow-up (mean duration was 5.6 to 6.7±1.8 years in DDKT and 6.2 to 7.4±1.7 years in LDKT), mean times of transplantation (era of transplantation) were: 1992±1.6 years and 2002±1.9 years for the CSA+AZA and CSA+MMF groups, respectively. There was no statistically significant difference in the Kaplan-Meier rates of graft loss due to disease recurrence of any glomerular disease studied between the CSA+AZA and CSA+MMF groups in either DDKT or LDKT recipients. Chi-square analysis revealed no statistically significant difference between the two immunosuppressive regimen groups in terms of age, gender and ethnic background. CONCLUSION: The OPTN/UNOS database revealed no difference in the rates of renal allograft loss due to disease recurrence of IgAN, MGN, MPGN, LN and FSGS among recipients receiving either CSA+AZA or CSA+MMF maintenance immunosuppressive therapy at 10-year follow-up.

Patients with diabetes mellitus type 2 and hypomagnesemia may have enhanced glomerular filtration via hypocalcemia.

INTRODUCTION: Hypomagnesemia and glomerular hyperfiltration are commonly observed in patients with diabetes mellitus Type 2 (DM2). In the current study, we examined the relationship between hypomagnesemia and glomerular filtration rates in DM2 patients. MATERIALS AND METHODS: Data were obtained for DM2 patients without documented kidney disease seen at UCLAOlive View Medical Center during January through March 2001. Data for hemoglobin, hemoglobin A1C (HbA1C), routine electrolytes, lipid profiles, urinalyses, history of hypertension, and pharmacy profiles were retrieved. Estimation of glomerular filtration rate (eGFR) was based on the CKD-epi formula. Multivariate analyses were performed to determine the correlations between eGFR and clinical factors including age, gender, history of hypertension, the use of diuretics, renin angiotensin system (RAS) inhibitors, acetylsalicylic acid, and statins, serum calcium, magnesium, hemoglobin, HbA1C lipid profile, and degree of proteinuria. RESULTS: 550 patients (54% females) with mean age 57.5 ± 11.0 years and eGFR 95.7 ± 14.8 ml/min/1.73 m2 were included. Multivariate analysis revealed negative correlations with eGFR for age (Pearson-correlationcoefficient: -0.7, p < 0.0001), hypertension (-0.32, p < 0.0001), magnesium (-0.21, p < 0.0001), calcium (-0.13, p = 0.009), proteinuria (-0.17, p < 0.0001), and the use of RAS inhibitors (-0.21, p < 0.0001), and diuretics (-0.24, p < 0.0001) and a positive correlation for HbA1C (0.28, p < 0.0001). Further analysis of the interaction between serum magnesium and calcium, defined as magnesium × calcium (Mg × Ca), revealed a more significant correlation with eGFR than either cation alone (-0.24, p < 0.0001). CONCLUSIONS: Serum magnesium, calcium, and (Mg × Ca) all had significant negative correlations with eGFR. In particular, (Mg × Ca) had the strongest correlation with eGFR.

Optimal use of SGLT2 inhibitors in diabetic kidney transplant recipients.

Sodium-glucose cotransporter 2 inhibitor (SGLT2i), a glucosuric agent initially approved for use as an antidiabetic agent, was unexpectedly found to confer cardio-and reno-protective effects in individuals with or without type 2 diabetes mellitus. Despite mounting evidence suggesting that SGLT2i provides cardio- and reno-protective benefits in both diabetic and non-diabetic and in chronic kidney disease (CKD) patients in the general population, reservations for its use in the transplant setting persist due to concerns for increased risk of genital mycotic and urinary tract infections. A comprehensive review of the literature on the efficacy and safety of SGLT2i use in diabetic kidney transplant recipients is herein presented followed by authors' opinion on its optimal use in this patient population.

Immunosuppressive management of dialysis patients with recently failed transplants.

Over the past decade, patients returning to dialysis after a failed transplant comprised of 5-10% of the annual number of dialysis initiations in the United States, whereas retransplant candidates account for 5.0-13% of the annual deceased donor wait-list additions. The United States Renal Data System (USRDS) database revealed a >3-fold increase in the annual adjusted death rates for patients returning to dialysis after graft loss compared with patients with a functioning allograft (9.4% vs. 2.8%, respectively). Continuation of low-dose immunosuppression to maintain residual allograft function has been suggested as a contributing factor, presumably via treatment-related infectious and cardiovascular complications among others. In contrast, a survival advantage in maintaining patients on long-term immunosuppression after returning to peritoneal dialysis has also been suggested. Despite the significant number of patients requiring reinitiation of some form of renal replacement therapy after a failed transplant and the increasing evidence suggesting their high mortality and morbidity rates, management of the failed allograft in these patients has received little attention. This article presents an overview of the literature on the management of immunosuppression after allograft failure, a brief review on the pros and cons of allograft nephrectomy, and the authors' opinions on the management of immunosuppression in patients with a failed kidney allograft.

The Effectiveness of Health Education in Improving Knowledge about Hypoglycemia and Insulin Pen Use among Outpatients with Type 2 Diabetes Mellitus at a Primary Care Hospital in Vietnam.

BACKGROUND: Patients with type 2 diabetes mellitus (T2DM) who have limited knowledge about hypoglycemia and insulin pen use are likely to have hypoglycemia and other complications. OBJECTIVE: This study aimed to evaluate the effectiveness of health education on knowledge about hypoglycemia and insulin pen use among outpatients with T2DM at a primary care hospital in Vietnam. METHODS: A pretest-posttest study was conducted among 80 patients with T2DM at District 11 Hospital in Ho Chi Minh City, Vietnam. At baseline, patients were interviewed through a predefined, structural questionnaire to assess their knowledge about hypoglycemia and insulin pen use. After that, patients underwent an individual health education session about hypoglycemia and insulin pen. One month and two months after this intervention, knowledge about hypoglycemia and insulin pen use were recorded again. RESULTS: The majority were males (65.0%) and the mean age was 59.6 (standard deviation 8.1, range 35-75) years. Very few patients had good knowledge and proper insulin pen use, with percentages ranging from 13.8% to 60%. There was a significant improvement of knowledge and practice after the intervention. Such improvement remained high one month and two months after the intervention. CONCLUSIONS: The health education intervention is effective in improving knowledge and practice in this population. There is a pressing need for such intervention at primary care hospitals to optimize treatment for patients with T2DM, possibly focusing on those who had characteristics to have the best effectiveness found in this study.

Severe Hyperphosphatemia in a Patient with Mild Acute Kidney Injury.

Hyperphosphatemia may arise from various conditions including exogenous ingestion, extracellular shifts due to cell death or alterations in acid-base status, increased bone resorption, hormonal dysregulations leading to reduced renal excretion, reduced kidney function, or faulty measurement techniques. We herein present a case of a young pregnant woman who presented with mild acute kidney injury (AKI), invasive mucormycosis receiving liposomal amphotericin, and hyperphosphatemia out of proportion to the degree of kidney injury. While the patient was given routine phosphate-binding agent by her primary care team for presumed AKI-associated hyperphosphatemia, a full investigation by the renal consulting team for contributing factors other than kidney injury revealed that she actually had pseudohyperphosphatemia associated with the use of liposomal amphotericin. Erroneous treatment of pseudohyperphosphatemia may have been detrimental to this pregnant patient. A literature review for conditions associated with pseudohyperphosphatemia other than the use of liposomal amphotericin will be discussed.

Healthcare Workers' Emotions, Stressor Experiences and Coping Strategies During the COVID-19 Pandemic in Vietnam.

PURPOSE: Healthcare workers (HCWs) are a crucial resource in the battle against the COVID-19 pandemic but are vulnerable to both SARS-CoV-2 infection and negative psychological consequences. This study evaluated HCWs' emotions, stressor experiences and coping strategies during the pandemic. METHODS: A cross-sectional study was conducted among HCWs at the University Medical Center in Ho Chi Minh City. The questionnaire was adapted from the MERS-CoV Staff Questionnaire to measure HCWs' emotions, stressor experiences and coping strategies during the COVID-19 pandemic. RESULTS: Among the 1423 participants eligible in the data analysis, the majority were female (71.1%) with a mean age of 34.2 (standard deviation 7.8) years. While most participants reported that they did their job because of their professionalism and duty as HCWs (87.4%), a high number reported feeling nervous and scared (86.0%). Most participants reported worry about transmitting SARS-CoV-2 to their families or friends (76.6%) and concern that a small mistake or lapse in concentration could infect themselves and others (76.7%). The most common coping strategies were following strict personal protective measures (95.3%), avoiding going out (92.5%) and reading about SARS-CoV-2 (92.3%). Females who had a higher educational level and less than 5-years work experience and those who worked at clinical departments and subclinical departments were more vulnerable. CONCLUSION: This study indicates an urgent need for psychological support for HCWs, especially for those at high risk of having stress. Interventions and support should utilize psychological resources and approaches effectively to adapt to the new situation during the COVID-19 pandemic.

Evaluation of adult kidney transplant candidates.

Important advances in immunosuppressive therapy and refinement in surgical techniques have allowed renal transplantation to become the treatment of choice for virtually all suitable candidates with end-stage renal disease. Compared to dialysis, kidney transplantation improves both patient survival and quality of life and, over time, can reduce the total cost of medical care. It must be noted, however, that although the risk of death in the first year after transplantation is <5%, not all patients qualify for the surgery because of their unacceptable risks for complications. The transplant evaluation process requires a comprehensive assessment of each patient's medical, surgical, and psychosocial histories. Selection of the suitable transplant candidate remains a challenge for transplant physicians owing, predominantly, to the presence of complex medical issues in the potential candidates and nonstandardized criteria for acceptance or rejection among transplant centers. Furthermore, with the ever-increasing disparity between donor organ supply and demand and resultant increased wait-list times, the transplant physicians must further consider the optimal management and re-evaluation of wait-list patients during the waiting period. This article describes a systematic approach for the evaluation of a potential renal transplant candidate. Various medical issues that arise during the evaluation process are discussed.