Rehabilitation exercises for kidney transplant recipients in an organ transplant ward: a best practice implementation project.

INTRODUCTION AND OBJECTIVES: Kidney transplantation is an effective treatment for end-stage kidney disease. Kidney transplant recipients (KTRs) are prone to experiencing reduced physical function, depression, fatigue, and lack of exercise motivation due to their sedentary lifestyle before surgery. Exercise is an effective intervention for KTRs, but it has not been properly implemented in many practice settings. This project aimed to promote evidence-based exercises as part of KTRs' rehabilitation to improve their health outcomes. METHODS: This project was informed by the JBI Evidence Implementation Framework. The project was conducted in the organ transplant ward of a tertiary comprehensive hospital in Changsha, China. Based on a summary of best evidence, 12 audit criteria were developed for the baseline and follow-up audits involving 30 patients and 20 nursing staff. The JBI Practical Application of Clinical Evidence System (PACES) and Getting Research into Practice (GRiP) tool were used to identify barriers and facilitators and develop targeted strategies to improve issues. RESULTS: Compared with the baseline audit, significant improvements were achieved in most of the criteria in the follow-up audit, with 9 of the 12 criteria reaching 100% compliance. Notably, the 6-minute walk distance test results were significantly higher, while the Self-Rating Depression Scale and Self-Rating Anxiety Scale scores were significantly lower ( p < 0.05). CONCLUSIONS: This project demonstrates that evidence-based practice can improve the clinical practice of rehabilitation exercises for KTRs. The GRiP strategies proved to be extremely useful, notably, the formulation of a standardized rehabilitation exercise protocol, training, and enhancement of the exercising environment. Head nurses' leadership and decision-making also played an important role in the success of this project. SPANISH ABSTRACT: http://links.lww.com/IJEBH/A180.

Evaluation of the use of a Renal Health application by kidney transplant recipients / Avaliação do uso do aplicativo Renal Health por transplantados renais / Evaluación del uso de la Aplicación Renal Health por parte de los receptores de trasplante renal

Abstract Objective: to evaluate the use of a renal health application by kidney transplant recipients. Method: a retrospective, observational study with a sample composed of individuals registered in the kidney transplant section of the application from July of 2018 to April of 2021. Demographic data, data entry, time of use, weight, blood pressure, blood glucose, creatinine, medication schedules, appointments, and tests were the variables collected. Descriptive analysis of the data was performed. Results: eight hundred and twenty-three downloads of the application were identified, and 12.3% of those were registered as kidney transplant recipients, the majority from southeastern Brazil (44.9%), 36±11 years old, and female (59.1%). Of the sample, 35.1% entered information such as creatinine (62%), weight (58.2%), and blood pressure (51.8%). Most used the application for one day (63.3%) and 13.9% for more than one hundred days. Those who used it for more than one day (36.7%) recorded weight (69%), medication intake (65.5%) and creatinine (62%), and scheduled appointments (69%). Conclusion: the kidney transplant recipient section of the Renal Health application generated interest in the young population, but showed low adherence throughout the assessed months. These results offer a relevant perspective on the implementation of mHealth technologies in kidney transplantation.

Resumo Objetivo: avaliar o uso do aplicativo Renal Health por transplantados renais. Método: estudo observacional retrospectivo com amostra composta por usuários que realizaram cadastro na seção para transplantados renais do aplicativo de julho de 2018 a abril de 2021. Foram coletadas as seguintes variáveis: dados demográficos, inserção de dados, tempo de uso, registros de peso, pressão arterial, glicemia, creatinina, horários das medicações, consultas e exames. Realizou-se análise descritiva dos dados. Resultados: houve 1.823 downloads do aplicativo e 12,3% cadastraram-se na seção para transplantados renais, a maioria do Sudeste do Brasil (44,9%), com 36±11 anos e do sexo feminino (59,1%). Da amostra, 35,1% inseriram informações como creatinina (62%), peso (58,2%) e pressão arterial (51,8%). A maioria utilizou o aplicativo por um dia (63,3%) e 13,9% por mais de cem dias. Os que utilizaram por mais de um dia (36,7%), inseriram peso (69%), agendaram consultas (69%), medicações (65,5%) e creatinina (62%). Conclusão: a seção para transplantados renais do aplicativo Renal Health despertou interesse na população jovem, mas apresentou baixa adesão ao longo dos meses avaliados. Esses resultados oferecem perspectiva relevante na implementação de tecnologias mHealth no transplante renal.

Resumen Objetivo: evaluar el uso de la aplicación Renal Health por parte de los receptores de trasplante renal. Método: estudio observacional retrospectivo con una muestra compuesta por usuarios que se registraron en la sección de trasplantados renales dentro de la aplicación desde julio de 2018 hasta abril de 2021. Se recolectaron las siguientes variables: datos demográficos, ingreso de datos, tiempo de uso, registros de peso, presión arterial, glucosa en sangre, creatinina, esquemas de medicación, consultas y exámenes. Se realizó un análisis descriptivo de los datos. Resultados: Ocurrieron 1.823 descargas de la aplicación y 12,3% se registró en la sección de trasplantados, la mayoría del sudeste de Brasil (44,9%), con edad de 36±11 años y del sexo femenino (59,1%). De la muestra, 35,1% ingresó información como: creatinina (62%), peso (58,2%) y presión arterial (51,8%). La mayoría utilizó la aplicación durante un día (63,3%) y el 13,9% más de cien días. Quienes lo usaron por más de un día (36,7%), agregaron peso (69%), programación de consultas (69%), medicación (65,5%) y creatinina (62%). Conclusión: la sección para trasplantados renales de la aplicación Renal Health despertó interés en la población joven, pero mostró baja adherencia en los meses evaluados. Estos resultados ofrecen una perspectiva relevante en la implementación de tecnologías mHealth en el trasplante renal.

Caracterización de la evolución clínica del trasplante renal en pacientes con virus de la hepatitis C positivo / Characterization of the clinical course of kidney transplantation in patients with positive hepatitis C virus

Introducción: La infección por el virus de la hepatitis C es un evento común en los receptores de trasplante renal que la arrastran desde su estancia en los tratamientos de hemodiálisis previos al implante. La positividad al virus C se ha asociado a una evolución desfavorable después del trasplante, dado por una mayor frecuencia de complicaciones clínicas, metabólicas e inmunológicas que repercuten de forma negativa tanto en la supervivencia del injerto como del paciente. Objetivos: Caracterizar la evolución clínica de los pacientes trasplantados de riñón con virus de la hepatitis C positivo y determinar la evolución de este grupo de enfermo de acuerdo a variables demográficas, clínicas y de supervivencia. Método: Estudio analítico, transversal, retrospectivo en pacientes trasplantados renales del Hospital Clínico Quirúrgico Hermanos Ameijeiras, desde el año 2005 al 2017. Se excluyeron los menores de 15 años, los retrasplantes, los trasplantes dobles y los combinados o cuando no se pudo obtener la información. Se comparan las variables escogidas entre enfermos que llegan al trasplante con serología positiva al virus C, (HVC positivos), con los HVC negativos. Resultados: Del total de 156 enfermos, 65 por ciento (102) fueron HVC positivos, no se encontraron diferencias entre grupo en cuanto a edad y sexo de receptores y donantes, así como tampoco en el tratamiento inmunosupresor utilizado. El donante vivo se empleó menos en los HVC positivos donde se encontraron más enfermos con poliquistosis renal. La necrosis tubular aguda (NTA) y el rechazo fueron más frecuentes en los HVC positivos, siendo la primera estadísticamente significativa, p=0,0421, también resultaron significativamente más frecuente en el grupo HVC positivo, la proteinuria, p=0,041, la elevación de enzimas hepáticas, p=0,047 y la diabetes postrasplante, p=0,047. La supervivencia del injerto y los pacientes fue menor en los HVC positivos. Conclusiones: En este estudio la hepatitis por virus C impacta negativamente en la evolución del injerto y propicia la aparición de algunas complicaciones clínicas, lo que sin dudas pudiera influir en una menor expectativa de vida tanto para el injerto como para el enfermo(AU)

Introduction: Hepatitis C virus infection is a common event in kidney transplant recipients that has dragged it along since their stay in hemodialysis treatments prior to implantation. Positivity to virus C has been associated with an unfavorable evolution after transplantation, due to higher frequency of clinical, metabolic and immunological complications that negatively affect both graft and patient survival. Objectives: To describe the clinical evolution of kidney transplant patients with positive hepatitis C virus and to determine the evolution of this group of patients according to demographic, clinical and survival variables. Method: An analytical, cross-sectional, retrospective study in kidney transplant patients at Hermanos Ameijeiras Hospital was carried out from 2005 to 2017. This study excluded children under 15 years of age, re-transplants, double and combined transplants or when it was not possible to gather the information. The variables chosen among patients who arrive at transplantation with positive serology for virus C (positive HCV) were compared with negative HCV. Results: One hundred and fifty six patients were the total, 65 percent (102) were HVC positive, no differences were found between groups in terms of age and sex of recipients and donors, nor in the immunosuppressive treatment used. The living donor was less used in positive HVC where more patients with polycystic kidney disease were found. Acute tubular necrosis (ATN) and rejection were more frequent in positive HVC, the former being statistically significant, p = 0.0421, proteinuria, p = 0.041, elevation was also significantly more frequent in the positive HVC group of liver enzymes, p = 0.047 and post-transplant diabetes, p = 0.047. Graft and patient survival was lower in positive HCV. Conclusions: In this study, hepatitis C virus has negative impact on the evolution of the graft and favors the appearance of some clinical complications, which undoubtedly could influence a shorter life expectancy for both the graft and the patient(AU)

Weight Gain, Energy Intake, Energy Expenditure, and Immunosuppressive Therapy in Kidney Transplant Recipients.

BACKGROUND: Weight gain after kidney transplantation is a common health problem. The factors in weight gain after kidney transplant include many factors such as age, ethnicity, gender, change in lifestyle (eg, kilocalorie intake and physical activity level), and immunosuppressive therapy. RESEARCH QUESTIONS: This study aimed to evaluate the relationship between weight gain and energy intake in dietary, energy expenditure in physical activity, and immunosuppressive therapy in kidney transplant recipients. DESIGN: This prospective, observational study included 51 participants who underwent kidney transplant, during 6 months from the start of the study. Anthropometric measurements were performed at first week, third- and sixth-month follow-ups of transplant recipients. Participants also completed 3-day "Dietary Record Form" and the "Physical Activity Record Form" at each follow-up. Simple frequency, analysis of variance analysis, and correlation analysis were used for data analysis. RESULTS: Weight gain in sixth month follow-up compared to baseline value was positively related to energy intake in first week (r = 0.59), third month (r = 0.75), and sixth month (r = 0.67) follow-ups, and energy expenditure in first week (r = 0.35) and sixth month (r = 0.34) follow-ups. However, weight gain was negatively related to mycophenolate mofetil dose (mg/d) in sixth month (r = -0.31) follow-up (P < .05). DISCUSSION: The results of this study provide an opportunity to reflect and discuss on modifiable risk factors such as energy intake and energy expenditure that affect weight gain posttransplantation in participants. It also examines the relationship between immunosuppressive therapy. Additionally, these results can be effective in designing interventions and managing risk factors to achieve weight management goals.

Tacrolimus trough levels higher than 6 ng/mL might not be required after a year in stable kidney transplant recipients.

BACKGROUND: Little is known regarding optimal tacrolimus (TAC) trough levels after 1 year post-transplant in stable kidney transplant recipients (KTRs) who have not experienced renal or cardiovascular outcomes. This study aimed to investigate the effect of 1-year post-transplant TAC trough levels on long-term renal and cardiovascular outcomes and opportunistic infections in stable KTRs. METHODS: KTRs receiving TAC with mycophenolate-based immunosuppression who did not experience renal or cardiovascular outcomes within 1 year post-transplant were enrolled from a multicenter observational cohort study. Renal outcome was defined as a composite of biopsy-proven acute rejection, interstitial fibrosis and tubular atrophy, and death-censored graft loss. Cardiovascular outcome was defined as a composite of de novo cardiomegaly, left ventricular hypertrophy, and cardiovascular events. Opportunistic infections were defined as the occurrence of BK virus or cytomegalovirus infections. RESULTS: A total of 603 eligible KTRs were divided into the low-level TAC (LL-TAC) and high-level TAC (HL-TAC) groups based on a median TAC level of 5.9 ng/mL (range 1.3-14.3) at 1 year post-transplant. The HL-TAC group had significantly higher TAC trough levels at 2, 3, 4, and 5 years compared with the levels of the LL-TAC group. During the mean follow-up of 63.7 ± 13.0 months, there were 121 renal outcomes and 224 cardiovascular outcomes. In multivariate Cox regression analysis, LL-TAC and HL-TAC were not independent risk factors for renal and cardiovascular outcomes, respectively. No significant differences in the development of opportunistic infections and de novo donor-specific anti-human leukocyte antigen antibodies and renal allograft function were observed between the two groups. CONCLUSIONS: TAC trough levels after 1 year post-transplant remained at a similar level until the fifth year after kidney transplantation and were not directly associated with long-term outcomes in stable Korean KTRs who did not experience renal or cardiovascular outcomes. Therefore, in Asian KTRs with a stable clinical course, TAC trough levels higher than approximately 6 ng/mL might not be required after a year of kidney transplantation.

Home-based inspiratory muscle training in pediatric patients after kidney transplantation: a randomized clinical trial.

BACKGROUND: Chronic kidney disease (CKD) represents the irreversible stages of renal failure and is a growing worldwide public health issue associated with increases in morbidity, mortality, and decreased quality of life. Kidney transplantation is considered one of the best treatment options in this population. However, even after surgery, respiratory muscle strength is below normal values, and inspiratory muscle training (IMT) improves respiratory muscle function, strength, and endurance. This study aimed to evaluate the effects of IMT regarding respiratory muscle strength, functional capacity, and pulmonary function in pediatric kidney transplant recipients with CKD, and secondarily, to assess the biochemical profile of patients after intervention. METHODS: This is a randomized, double-blind, placebo-controlled trial. Patients were randomized into two groups, intervention (IG) and control (CG) and performed IMT home-based training for 6 weeks. In the IG, the load was adjusted to 40% of the maximal inspiratory pressure and in the CG was adjusted to a minimum placebo load (9 cm H2O). RESULTS: Thirty-one patients were randomly allocated to the intervention (n = 16) or control (n = 15) groups. There were no differences at baseline between groups. Increase of 35% in the maximal inspiratory pressure predicted and 26% in the maximal expiratory pressure predicted in the IG were found, compared with 5 and 4% in the CG. There was an increase in hemoglobin and hematocrit values in the IG. CONCLUSIONS: Home-based IMT provides a significant increase in respiratory muscle strength, without changes in functional capacity and pulmonary function. Benefits regarding biochemical markers (hemoglobin and hematocrit) were also observed.

Brain function and metabolism in patients with long-term tacrolimus therapy after kidney transplantation in comparison to patients after liver transplantation.

BACKGROUND: About 50% of the patients 5-7 years after kidney transplantation show impairment of memory, attention and executive function. Tacrolimus frequently induces neurological complications in the first few weeks after transplantation. Furthermore, tacrolimus treatment is associated with impaired cognitive function in the long-term in patients after liver transplantation. We hypothesize that long-term tacrolimus therapy is associated with cognitive dysfunction and alterations of brain structure and metabolism in patients after kidney transplantation. METHODS: Twenty-one patients 10 years after kidney transplantation underwent cognitive testing, magnetic resonance imaging and whole brain 31-phosphor magnetic resonance spectroscopy for the assessment of brain function, structure and energy metabolism. Using a cross-sectional study design the results were compared to those of patients 1 (n = 11) and 5 years (n = 10) after kidney transplantation, and healthy controls (n = 17). To further analyze the share of transplantation, tacrolimus therapy and kidney dysfunction on the results patients after liver transplantation (n = 9) were selected as a patient control group. RESULTS: Patients 1 and 10 years after kidney transplantation (p = 0.02) similar to patients 10 years after liver transplantation (p<0.01) showed significantly worse cognitive function than healthy controls. In contrast to patients after liver transplantation patients after kidney transplantation showed significantly reduced adenosine triphosphate levels in the brain compared to healthy controls (p≤0.01). Patients 1 and 5 years after kidney transplantation had significantly increased periventricular hyperintensities compared to healthy controls (p<0.05). CONCLUSIONS: Our data indicate that cognitive impairment in the long-term after liver and kidney transplantation cannot exclusively be explained by CNI neurotoxicity.

Double J stent is superior to externally draining ureteric stent in enhancing recovery after kidney transplantation - A prospective cohort study.

BACKGROUND: Routine intraoperative ureteric stenting lowers the rate of urological complications after kidney transplantation. However, there is no consensus about the optimal stent design and duration. The aim of this prospective cohort study was to compare the influence of double J (JJ) stents and externally draining percutaneous (PC) stents on the early quality of recovery after living donor kidney transplantation. MATERIALS AND METHODS: A prospective cohort study was performed in two consecutive cohorts of 40 patients who underwent living donor kidney transplantation at the Radboud university medical center between April 2016 and October 2017. The first cohort of 40 patients received a 6-French externally draining PC stent. The second cohort of 40 patients received a 6-French/14 cm JJ stent. We compared the influence of the stent design on the quality of early post-operative recovery (measured by the Quality of Recovery-40 questionnaire) and the length of hospital stay. RESULTS: Patients with a JJ stent scored significantly better on the Quality of Recovery score on the third and fifth postoperative day, when compared to patients with a PC stent. Furthermore, in comparison to patients with a PC stent, patients with a JJ stent were earlier mobilising and independent in daily activities, resulting in a shorter length of hospital stay. The number of postoperative urological complications was comparable between the two groups. CONCLUSION: The use of JJ stents during living donor kidney transplantations improves the postoperative recovery and shortens the length of hospital stay, when compared to PC stents without compromising the number of postoperative urological complications.

Long-term outcome of renal transplantation: a 10-year follow-up of 765 recipients.

INTRODUCTION: Renal transplantation is a treatment of choice for patients with end­stage renal disease. The main goal of transplant care is to achieve the best long­term patient survival (PS) and graft survival (GS). OBJECTIVES: We aimed to assess the impact of various immunosuppression (IS) protocols on PS and GS following renal transplantation. PATIENTS AND METHODS: This was a retrospective single­center cohort study including a total of 765 consecutive adult renal transplant recipients (RTRs) who underwent transplantation between 1998 and 2003. The primary endpoints included PS and GS. The secondary endpoints were graft function determined by estimated glomerular filtration rate and hospitalization length per patient per year. RESULTS: Ten­year PS and GS rates were 88.6% and 78.7%, respectively. The intent­to­treat (ITT) group received IS that was later changed, whereas in the group on randomized therapy (ORT), the same IS protocol was maintained during follow­up. The ITT group had significantly better PS and GS than the ORT group. In the ITT group, patients treated with a combination of tacrolimus (TAC) and azathioprine (AZA), cyclosporine (CSA) and AZA, or CSA and mycophenolic acid metabolites (MPAs) had significantly better PS than those treated with TAC and MPA. The ORT group receiving AZA in any combination also had significantly better PS than MPA­treated individuals. CONCLUSIONS: The effect of IS protocols on long­term outcomes varies depending on patient subpopulations. Immunosuppressive therapy solves rejection­related problems but does not address the increasing mortality of RTRs due to cardiovascular diseases, malignancies, or infections. Therefore, treatment recommendations should be individualized and posttransplant care, provided mainly by internists, should be carefully structured to improve long­term outcomes of renal transplantation.

Predicting urine output after kidney transplantation: development and internal validation of a nomogram for clinical use

ABSTRACT Purpose: To analyze pre-transplantation and early postoperative factors affecting post-transplantation urine output and develop a predictive nomogram. Patients and Methods: Retrospective analysis of non-preemptive first transplanted adult patients between 2001-2016. The outcomes were hourly diuresis in mL/Kg in the 1st (UO1) and 8th (UO8) postoperative days (POD). Predictors for both UO1 and UO8 were cold ischemia time (CIT), patient and donor age and sex, HLA I and II compatibility, pre-transplantation duration of renal replacement therapy (RRT), cause of ESRD (ESRD) and immunosuppressive regimen. UO8 predictors also included UO1, 1st/0th POD plasma creatinine concentration ratio (Cr1/0), and occurrence of acute cellular rejection (AR). Multivariable linear regression was employed to produce nomograms for UO1 and UO8. Results: Four hundred and seventy-three patients were included, mostly deceased donor kidneys' recipients (361, 70.4%). CIT inversely correlated with UO1 and UO8 (Spearman's p=-0.43 and −0.37). CR1/0 inversely correlated with UO8 (p=-0.47). On multivariable analysis UO1 was mainly influenced by CIT, with additional influences of donor age and sex, HLA II matching and ESRD. UO1 was the strongest predictor of UO8, with significant influences of AR and ESRD. Conclusions: The predominant influence of CIT on UO1 rapidly wanes and is replaced by indicators of functional recovery (mainly UO1) and allograft's immunologic acceptance (AR absence). Mean absolute errors for nomograms were 0.08 mL/Kg h (UO1) and 0.05 mL/Kg h (UO8).

Exercise training in kidney transplant recipients: a systematic review.

BACKGROUND AND AIMS: Evidences on the benefits of physical exercise in kidney transplant patients (KTx) are not conclusive and concerns on safety remain. We here gather and interpret current evidence on the benefits/harms of exercise training intervention in KTx. METHODS: Systematic review of exercise training programs in KTx. RESULTS: A total of 24 studies including 654 KTx patients on intervention and 536 controls were evaluated. The median age was 46 years; the transplant vintage was 2 days to 10 years. The intervention was an aerobic or resistance exercise program or a combination of both; interventions consisted of 20-60 min' sessions, 2-3 times per week repetitions and 5.5 months' median duration. Most studies improved cardiorespiratory fitness (expressed as VO2peak) as well as maximum heart rate, which was associated with a significant increase in muscle performances and strength. No significant changes in body weight or composition were observed, but a trend towards weight reduction in overweight or obese patients on stable KTx was noted. The arterial blood pressure reduced a little after exercise when it was high at start. Exercise intervention had no clinically relevant impact on anaemia, glycaemia or lipidaemia. In contrast, exercise training improved several aspects of quality of life. No data on long-term hard outcomes or on high-risk subpopulations such comorbid or elderly patients were available. CONCLUSIONS: In adult kidney transplant patients, a structured physical exercise program improved the aerobic capacity and ameliorated muscle performance and quality of life. No harms were observed in the short-term, but long-term RCTs are required. Overall, in mid-age kidney transplant patients without major comorbidities, an aerobic or resistance supervised exercise lasting 3-6 months could be suggested within the comprehensive treatment of kidney transplant.

Comparing dialysis centre mortality outcomes across Australia and New Zealand: identifying unusually performing centres 2008-2013.

BACKGROUND: Comparing the mortality profiles of dialysis centres is important to ensure that high standards of care are maintained. We compare the performance of dialysis centres in Australia and New Zealand in their treatment of haemodialysis patients, accounting for the competing risks of kidney transplantation and transfer to peritoneal dialysis. METHODS: Observational cohort study. We included data from all adult patients (5574 patients) commencing haemodialysis at home or in a facility between 2008 and 2010 across 62 dialysis centres, from the Australia and New Zealand Dialysis and Transplant Registry. Standardised mortality ratios were calculated by estimating mortality probabilities from a pooled random effects logistic regression model, accounting for the competing risk of transplantation using an inverse probability weighting approach. Models were adjusted for patient comorbidities, sex, height, weight, late referral to a nephrologist, age, race, primary kidney disease, smoking status, and serum creatinine (µmol/l). RESULTS: Two dialysis centres were found to have relatively higher levels of risk-adjusted mortality lying outside the prediction intervals for "usual" performance. Risk adjusted mortality rates were not associated with centres' compliance with guidelines for vascular access and biochemical and haematological targets. CONCLUSIONS: We demonstrate that standardised mortality ratios are useful to identify facilities that have statistically outlying mortality risk. Our criterion for determining whether a centre has better or worse performance than expected is statistical, and thus analyses such as ours can serve only as a screening tool, and are only one aspect of assessment of "quality" of performance.

Post-Renal Transplantation Outcomes in Elderly Patients Compared to Younger Patients in the Setting of Early Steroid Withdrawal.

BACKGROUND: Previous studies reported improved outcomes for renal recipients undergoing early steroid withdrawal (ESW), with significantly lower rates of new-onset diabetes, cytomegalovirus (CMV), and malignancy. As renal transplants in older adults has increased, studies have shown similar outcomes between elderly and younger patients. We aim to evaluate post-renal transplantation outcomes in elderly patients compared to younger patients who have undergone ESW. METHODS: A retrospective analysis of adults who received transplants between January 2004 and December 2014 and received either basiliximab or antithymocyte globulin for induction, underwent ESW, and received tacrolimus and mycophenolate for maintenance. Patients were stratified based on age (≥60 vs <60). The 1-year primary end point was a composite of patient survival, graft survival, biopsy-proven acute rejection, and serum creatinine. The secondary outcomes included renal function, the incidence of opportunistic infections, malignancies, diabetes, and cardiovascular complications. Cox regression was used to evaluate variables that may affect rejection. RESULTS: The sample included 292 patients; 72 were elderly individuals and 220 were younger adults. No significant differences were found in the primary end point or incidence of CMV, BK virus, or malignancy ( P = 1.0, .82, and .06, respectively). The use of blood pressure medications and the need for lipid-lowering agents were significantly higher in elderly patients at last follow-up. Diabetes was more common in elderly patients (15.2% vs 8.41%, P = .11). The induction agent used did not show any significant effect on rejection risk. CONCLUSION: We report similar outcomes in elderly patients compared to younger patients in the setting of ESW.

The importance of educational interventions for adherence to the immunosuppressant treatment program to kidney-transplanted patients / Importância de intervenções educativas para adesão ao tratamento imunossupressor em pacientes transplantados renais

Introduction: the non-adherence to the immunosuppressant treatment program is frequent in kidney transplanted patients. To promote the adherence to this therapeutic, specific educational interventions for every learning style, can help create better results. Objective: verify the relevance of educative interventions adjusted to different learning styles for immunosuppressive treatment adherence in kidney transplant patients. Methods: cohort study. Fifty-nine (59) kidney transplanted patients took part in the study. To evaluate adherence was used the Basel Assessment of Adherence Scale for Immunosuppressives (BAASIS) instrument. The learning styles were identified by the VARK questionnaire. Results: significant differences were observed in the second (p<0,001), third (p<0,001) and fourth (p=0,009) evaluate of the adherence, when compared with the first one. There wasn't found significant differences when related. They didn't go find differences significant when related the adhesion with the learning styles and too much demographic and clinical data. Conclusion: the adhesion to the imunossupressor doesn't seem to be associated to the specific interventions for each learning style.

Introdução: A não adesão ao tratamento imunossupressor é comum nos pacientes transplantados renais. Para promover a adesão à esta terapêutica, intervenções educativas específicas para cada estilo de aprendizagem, podem propiciar melhores resultados. Objetivo: Verificar a importância de intervenções educativas ajustadas ao estilo de aprendizagem com a adesão ao tratamento imunossupressor de pacientes transplantados renais. Métodos: Estudo de coorte. Participaram 59 pacientes transplantados renais. Para avaliar a adesão foi utilizado o instrumento Basel Assessment of Adherence Scale for Immunosuppressives (BAASIS). Os estilos de aprendizagem foram identificados pelo questionário VARK. Resultados: Foram observadas diferenças significativas na segunda (p<0,001), terceira (p<0,001) e quarta (p=0,009) avaliação da adesão, quando comparadas à primeira. Não foram encontras diferenças significativas quando relacionada a adesão com os estilos de aprendizagem e demais dados demográficos e clínicos. Conclusão: A adesão ao imunossupressor não parece estar associada às intervenções específicas para cada estilo de aprendizagem.

A comunicação como ferramenta educativa no préoperatório mediato de transplante renal / The communication as an educational tool during kidney transplantation preoperative period / La comunicación como herramienta educativa en el período pre-operatorio mediato de trasplante renal

Objetivo: O objetivo do estudo é reconhecer a importância da comunicação como ferramenta utilizada pelo enfermeiro no pré-operatório mediato do paciente em terapia hemodialítica indicada para transplante renal. Métodos: Trata-se de um estudo descritivo, convergente, com abordagem qualitativa. Os dados foram coletados por meio de entrevista semiestruturada com 9 enfermeiras, utilizando um roteiro pré-estabelecido com questões subjetivas das quais emergiram 2 categorias: Responsabilidade do enfermeiro na comunicação com o paciente; e Importância da comunicação enfermeiro/ paciente. Resultados: Os resultados apontam a relevância de estudar o processo da comunicação, pois, ao praticá-lo, há aperfeiçoamento do modo que o enfermeiro se comunica, evitando interferências que possam comprometer as informações prestadas. Conclusão: Ressalta-se a importância da relação enfermeiro/paciente, que possibilita o entendimento das informações educativas e o modo como são prestadas, constituindo poderosa ferramenta no pré-operatório mediato de transplante renal

Objetivo: El objetivo es reconocer la importancia de la comunicación como herramienta utilizada por los enfermeros en el paciente preoperatorio mediato en hemodiálisis indicado para el trasplante de riñón. Método: Se trata de un estudio descriptivo, convergente, con un enfoque cualitativo. Los datos fueron recogidos a través de entrevista semi-estructurada con 9 enfermeras, utilizando un guión pre-establecido con preguntas subjetivas de las que emergieron 2 categorías: Responsabilidad del enfermero en la comunicación con el paciente; e Importancia de la comunicación enfermero/ paciente. Resultados: Los resultados señalan la relevancia de estudiar el proceso de la comunicación, pues, practicándola, hay una mejora en la forma en que el enfermero se comunica, evitando interferencias que puedan poner en peligro las informaciones ofrecidas. Conclusión: Se destaca la importancia de la relación enfermero/paciente, que permite la comprensión de las informaciones educativas y la forma en que se prestan, constituyendo poderosa herramienta en el período pre-operatorio mediato de trasplante renal

Objective: The study's aim has been to recognize the importance of the communication as a tool used by the nurse over the preoperative period of patients undergoing hemodialysis therapy and indicated for having renal transplantation. Methods: It is a descriptive and convergent study with a qualitative approach. Data were collected through a semi-structured interview with 9 female nurses and using a pre-established script with subjective questions. By using this approach, the following 2 categories emerged: the nurse's responsibility in communicating to the patient; and the significance of nurse/patient communication. Results: The results point out the relevance of studying the communication process, because, by putting it into practice, there is an improvement regarding the nurse's communication skills, and then avoiding any interference that may affect the information provided. Conclusion: The significance of the nurse/patient relationship stands out, which enables understanding the educational information and the way in which they are provided, then constituting a powerful tool during the preoperative period of a renal transplantation

Benefits of multimodal enhanced recovery pathway in patients undergoing kidney transplantation.

BACKGROUND: Use of enhanced recovery after surgery (ERAS) pathways to accelerate functional recovery and reduce length of stay (LOS) has rarely been investigated in kidney transplantation (KTX). MATERIALS AND METHODS: Consecutive adult isolated KTXs between July 2015 and July 2016 (ERAS, n = 139) were compared with a historical cohort between January 2014 and July 2015 (HISTORIC, n = 95). RESULTS: Enhanced recovery after surgery recipients were significantly more likely to receive kidneys that were non-local (56.1% vs 4.2%), higher Kidney Donor Profile Index (36-85, 58.4% vs 45.2%; >85, 15.2% vs 10.7%), cold ischemia time ≥30 h (62.4% vs 4.7%), induced with antithymocyte globulin (97.1% vs 87.4%), and to develop delayed graft function (46.4% vs 25.0%). LOS was shorter by 1 day among ERAS (mean 4.59) compared to HISTORIC patients (mean 5.65) predominantly due to a shift in discharges within 3 days (32.4% vs 4.2%); 30-day readmission to the hospital (27.3% vs 27.4%) or emergency room visit (9.4% vs 7.4%) was similar. There was one 30-day death in the ERAS group and none in the HISTORIC group. Return to bowel function and early meal consumption were significantly associated with ERAS, however, with somewhat higher diarrhea and emesis rates. CONCLUSION: ERAS following KTX correlated with lower LOS without change in readmissions or ER visits despite higher delayed graft function rates.

The epidemiology of renal replacement therapy in two different parts of the world: the Latin American Dialysis and Transplant Registry versus the European Renal Association-European Dialysis and Transplant Association Registry / Datos epidemiológicos del tratamiento sustitutivo de la función renal en dos partes del mundo: el Registro Latinoamericano de Diálisis y Trasplante Renal frente al Registro de la Asociación Europea de Nefrología y Asociación Europea de Diálisis y trasplante / Epidemiologia da terapia renal substitutiva em dois pontos distintos do planeta: Registro Latino-Americano de Diálise e Transplante Renal e Registro da Associação Europeia de Nefrologia e Associação Europeia de Diálise e Transplante

ABSTRACT Objective To compare the epidemiology of renal replacement therapy (RRT) for end-stage renal disease (ESRD) in Latin America and Europe, as well as to study differences in macroeconomic indicators, demographic and clinical patient characteristics, mortality rates, and causes of death between these two populations. Methods We used data from 20 Latin American and 49 European national and subnational renal registries that had provided data to the Latin American Dialysis and Renal Transplant Registry (RLADTR) and the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry, respectively. The incidence and prevalence of RRT in 2013 were calculated per million population (pmp), overall and by subcategories of age, sex, primary renal disease, and treatment modality. The correlation between gross domestic product and the prevalence of RRT was analyzed using linear regression. Trends in the prevalence of RRT between 2004 and 2013 were assessed using Joinpoint regression analysis. Results In 2013, the overall incidence at day 91 after the onset of RRT was 181 pmp for Latin American countries and 130 pmp for European countries. The overall prevalence was 660 pmp for Latin America and 782 pmp for Europe. In the Latin American countries, the annual increase in the prevalence averaged 4.0% (95% confidence interval (CI): 2.5%-5.6%) from 2004 to 2013, while the European countries showed an average annual increase of 2.2% (95% CI: 2.0%-2.4%) for the same time period. The crude mortality rate was higher in Latin America than in Europe (112 versus 100 deaths per 1 000 patient-years), and cardiovascular disease was the main cause of death in both of those regions. Conclusions There are considerable differences between Latin America and Europe in the epidemiology of RRT for ESRD. Further research is needed to explore the reasons for these differences.

RESUMEN Objetivo Comparar los datos epidemiológicos del tratamiento sustitutivo de la función renal (TSFR) para la nefropatía terminal en América Latina y Europa, así como estudiar las diferencias en cuanto a indicadores macroeconómicos, características demográficas y clínicas de los pacientes, tasas de mortalidad y causas de defunción entre estas dos poblaciones. Métodos Utilizamos los datos de 20 registros renales latinoamericanos y 49 europeos, a nivel nacional y subnacional, que le habían proporcionado datos al Registro Latinoamericano de Diálisis y Trasplante Renal (RLADTR) y al Registro de la Asociación Europea Renal-Asociación Europea de Diálisis y Trasplantes (ERA-EDTA, por su sigla en inglés), respectivamente. Se calculó la incidencia y la prevalencia del TSFR en el 2013 por millón de habitantes, en total y por subcategoría (edad, sexo, nefropatía primaria y modalidad de tratamiento). Se analizó la correlación entre el producto interno bruto y la prevalencia de TSFR mediante regresión lineal. Se evaluaron las tendencias en la prevalencia de TSFR entre el 2004 y el 2013 mediante un análisis de regresiones lineales segmentadas. Resultados En el 2013, la incidencia general al día 91 después de iniciar el tratamiento sustitutivo de la función renal era de 181 por millón de habitantes en los países latinoamericanos y de 130 en los países europeos. La prevalencia general era de 660 por millón de habitantes para América Latina y de 782 para Europa. En los países latinoamericanos, el aumento anual promedio de la prevalencia fue de 4,0% (intervalo de confianza de 95% [IC]: 2,5%-5,6%) entre el 2004 y el 2013, mientras que los países europeos registraron un aumento anual promedio de 2,2% (IC de 95%: 2,0%-2,4%) durante el mismo período. La tasa bruta de mortalidad fue mayor en América Latina que en Europa (112 defunciones por 1 000 años-paciente, en comparación con 100 defunciones), y las enfermedades cardiovasculares fueron la principal causa de muerte en ambas regiones. Conclusiones Hay considerables diferencias entre América Latina y Europa en cuanto a los datos epidemiológicos del tratamiento sustitutivo de la función renal para la nefropatía terminal. Es necesario hacer más investigaciones para explorar las razones de tales diferencias.

RESUMO Objetivo Comparar o perfil epidemiológico de pacientes com doença renal em estágio final (DREF) em terapia renal substitutiva (TRS) na América Latina e na Europa e examinar as diferenças nos indicadores macroeconômicos, características demográficas e clínicas, taxas de mortalidade e causas de morte entre as duas populações de pacientes. Métodos O estudo foi baseado em informação de 20 registros latino-americanos e 49 registros nacionais e subnacionais europeus que haviam fornecido dados ao Registro Latino-Americano de Diálise e Transplante Renal (RLADTR) e Registro da Associação Europeia de Nefrologia e Associação Europeia de Diálise e Transplante (ERA-EDTA), respectivamente. A incidência e a prevalência de TRS em 2013 foram calculadas por milhão de habitantes (pmh), geral e por subcategorias de idade, sexo, doença renal primária e modalidade de tratamento. A correlação entre o produto interno bruto (PIB) e a prevalência de TRS foi analisada com o uso de regressão linear. Tendências na prevalência de TRS entre 2004 e 2013 foram analisadas com o uso de regressão linear segmentada. Resultados Em 2013, a incidência geral ao dia 91 do início de TRS foi 181 pmh nos países latino-americanos e 130 pmh nos países europeus. Observou-se uma prevalência geral de TRS de 660 pmh na América Latina e 782 pmh na Europa. No período 2004-2013, o aumento médio anual da prevalência foi de 4,0% (intervalo de confiança de 95% [IC 95%] 2,5%-5,6%) nos países latino-americanos, enquanto que houve um aumento médio anual de 2,2% (IC 95% 2,0%-2,4%) nos países europeus. A taxa de mortalidade bruta foi maior na América Latina que na Europa (112 versus 100 óbitos por 1.000 pacientes-anos) e doença cardiovascular foi a principal causa de morte em ambas as regiões. Conclusões Existem diferenças consideráveis entre a América Latina e a Europa no perfil epidemiológico dos pacientes com DREF em TRS. Outras pesquisas devem ser realizadas para investigar mais a fundo estas diferenças.

Special Considerations in Pediatric Kidney Transplantation.

Universally accepted as the treatment of choice for children needing renal replacement therapy, kidney transplantation affords children the opportunity for an improved quality of life over dialysis therapy. Immunologic and surgical advances over the last 15 years have improved the pediatric patient and kidney graft survival. Unique to pediatrics, congenital genitourinary anomalies are the most common primary diseases leading to kidney failure, many with urological issues. Early urological evaluation for post-transplant bladder dysfunction and emphasis on immunization adherence are the mainstays of pediatric pretransplant and post-transplant evaluations. A child's height can be challenging, sometimes requiring an intra-abdominally placed graft, particularly if the patient is <20 kg. Maintenance immunosuppression regimens are similar to adult kidney graft recipients, although distinctive pharmacokinetics may change dosing intervals in children from twice a day to thrice a day. Viral infections and secondary malignancies are problematic for children relative to adults. Current trends to reduce/remove corticosteroid therapy from post-transplant protocols have produced improved linear growth with less steroid toxicity; although these studies are still ongoing, graft function and survival are considered acceptable. Finally, all children with a kidney transplant need a smooth transition to adult clinics. Future research in pertinent psychosocial aspects and continued technological advances will only serve to optimize the transition process. Although some aspects of kidney transplantation are similar in children and adults, for instance immunosuppression and immunosuppressive regimens, and rejection mechanisms and their diagnosis using the Banff criteria, there are important differences this review will focus on and which continue to drive innovation.

Enhanced Recovery After Kidney Transplantation Surgery.

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols have gained widespread recognition in general surgery, decreasing the length of hospital stay while maintaining equivalent or lower morbidity and increased patient satisfaction. The feasibility of the ERAS protocol has not been studied in kidney transplantation. In this single-center retrospective case series, we describe the outcomes of 45 consecutive deceased-donor kidney transplant recipients subjected to a modified ERAS protocol, and we discuss the potential for future developments. METHODS: Included in the analysis were 45 consecutive deceased-donor kidney transplant recipients from August 2014 to July 2015 in the John Paul II Krakow Specialist Hospital, Krakow, Poland. All patients were subjected to a modified ERAS protocol. The primary outcomes were length of hospital stay and mortality and morbidity rates. A surrogate composite criterion for discharge was ability to attend the transplant clinic weekly with no need for dialysis. The secondary outcome was the rate of unplanned readmissions within the 1st 3 months after transplantation. RESULTS: The median hospital stay was 10 days (range, 6-46). There were no deaths or acute coronary or thromboembolic events. Serious complications requiring surgery occurred in 6.6% of recipients. Three-month graft survival was 97.8%. The unplanned readmission rate was 8.9%. CONCLUSIONS: ERAS protocol is feasible in deceased donor kidney transplantation and renders low morbidity rates and reasonable readmission rate. Further reduction of the length of the hospital stay can be expected with health care system financial policies.

[Influence of physical rehabilitation on quality of life after renal transplantation].

BACKGROUND: Aim of this study was to evaluate the role of physical rehabilitation to improve the quality of life (QOL) of people after kidney transplantation. PATIENTS AND METHODS: Analyzes the results of treatment of 57 recipients (mean age 35 +/- 9.65 years) donor kidney at different times of the postoperative period. Depending on the physical rehabilitation program allocated 3 groups of patients: group II--physical rehabilitation was carried out only in the first week after surgery to prevent early postoperative complications, in group I--during the year; in group III combined 30 relatively healthy people do not need an organ transplant and with a mean age 33.7 +/- 8.7 years, leading a normal life, not engaged in regular recreational physical culture. Quality of life was assessed using a questionnaire SF36 at 1, 3, 6 and a 12 months after surgery. RESULTS: One year after surgery in both groups compared with preoperative indicators marked improvement according to all scales of the questionnaire. However, in group I indicators of quality of life were higher than in group II from 11.4 to 19.7%, and even some items questionnaire SF-36 is higher than in group III which is associated with the physical rehabilitation. CONCLUSION: It has been shown that exercises is an important component of treatment and rehabilitation after kidney transplantation and help improve both the psychological and the physical component of quality of life.