A multidisciplinary approach to improving transition readiness in pediatric liver transplant recipients.

The Six Core Elements of Transition have been advocated to guide transition, but little is published about their use with liver transplant patients. We started a liver transplant transition program in August 2015 using quality improvement (QI) methods and by linking the Six Core Elements of Transition to process measures. Eligible patients completed baseline transition readiness assessments (Readiness for Transition Questionnaire, RTQ), interviews with a psychologist, received focused education, and completed follow-up RTQs before transfer to adult care. Our QI goal was to improve RTQ scores by 20% prior to transfer to adult care. We also assessed continuity of care, tacrolimus levels, rejection, and retransplantation as balancing measures. Of the 24 patients who completed the transition program and were transferred to adult care, RTQ scores were available for 11 patients. Overall RTQ scores improved from 23.7 to 30.5 (+28.7%, P = .009) prior to transfer. Nearly two-thirds (63%) of patients were seen by adult transplant hepatology within 6 months, and one patient was lost to follow-up after the first adult visit. Tacrolimus-level standard deviations were <2.0 in 45% of patients in pediatric care and 72% of patients in adult care. Three patients had undergone immunosuppression withdrawal in pediatric care, with one restarted on immunosuppression prior to transfer to adult care due to late acute rejection. The Six Core Elements of Transition can be translated into patient- and system-level transition milestones to serve as potential quality metrics in the implementation of transition programs.

A Feasibility Study for Teaching Older Kidney Transplant Recipients How to Wear and Use an Activity Tracker to Promote Daily Physical Activity.

Activity trackers have demonstrated promise in promoting physical activity in chronic disease populations, but few studies describe how participants were educated to use the activity tracker. The purpose of this study was to describe the teach-back method used to instruct older kidney transplant recipients to use an activity tracker/app and to describe the facilitators/challenges of wearing the activity tracker. A feasibility design was used for implementing the use of the tracker. A four-week follow-up questionnaire was administered to obtain participants' opinions on wear ing the tracker. The leading facilitator was the desire to track daily steps. The main challenge was securing the band. Reports of challenges were minimal, suggesting the teach-back method is feasible for teaching this population how to use an activity tracker.

Deficiencies in reproductive health counseling in liver transplant recipients.

BACKGROUND: In liver transplant (LT) recipients of childbearing age, there is often rapid return of fertility post-transplant. Our aim was to determine whether healthcare providers are documenting reproductive health counseling in LT recipients. METHODS: We performed a review of 365 LT recipients (164 female, 201 male) of childbearing age transplanted between 1994 and 2015 at a single center. We evaluated documentation of reproductive health counseling, content of the counseling and its provider. RESULTS: Reproductive health counseling was documented in 7% of LT recipients (14% of females, 0.5% of males). The transplant team provided the counseling in 56%, obstetrics/gynecology in 35%, and primary care in 9%. Twenty-four post-LT pregnancies occurred; these were unplanned in 13%. Miscarriage/stillbirth occurred in 7/24 pregnancies (29%). Mycophenolic acid was used by 20% of female recipients at conception. Only age at transplant (P = 0.001) and post-LT pregnancy was associated with documentation of reproductive health counseling in female recipients (P = 0.0001). CONCLUSION: Despite rapid return of fertility in reproductive-aged LT recipients, documentation of reproductive health counseling in this population is rare in men and women. This increases the potential for adverse maternal and fetal outcomes in this high-risk population.

Evaluating the feasibility of a nurse-led self-management support intervention for kidney transplant recipients: a pilot study.

BACKGROUND: To support effective self-management after kidney transplantation, a holistic nurse-led self-management support intervention was developed using the Intervention Mapping approach. The primary aim was to evaluate the feasibility, acceptability and fidelity of the intervention for kidney transplant recipients and professionals. The secondary aim was to explore preliminary effects on outcomes. METHODS: A pilot study was conducted in 2015-2017 to evaluate the intervention. Nurse Practitioners (NP) guided recipients in assessing 14 life areas using the Self-Management Web. Participants were supported in developing self-regulation skills which can be applied to self-management of the illness. Strategies included goal setting, action planning, and promotion of motivation and self-efficacy. Adult recipients from an outpatient clinic of a Dutch University Hospital who underwent their transplant at least 1 month ago, were invited to participate. NPs, nephrologists and recipients were interviewed to assess feasibility, fidelity and implementation experience. Consultations were videoed and analysed to assess fidelity. To assess the preliminary effects, the intervention group completed baseline (T0) and follow-up (T1) questionnaires on self-management behavior, self-efficacy, quality of life and quality of care. A historical control group of kidney transplant recipients completed the same questionnaires at T1. RESULTS: Twenty-seven recipients agreed to participate in the intervention group, of which 24 completed the intervention and 16 completed baseline and follow-up surveys. The control group consisted of 33 recipients. Professionals and recipients appraised the open, holistic focus of the intervention as a welcome addition to standard care and felt that this helped to build a relationship of trust. Recipients also felt they became more competent in problem-solving skills. The within-group analysis showed no significant increase in patients' self-management skills. The between-groups analysis showed significantly higher medication adherence among the intervention group (P = 0.03; G = 0.81). The within-groups analysis showed a significantly higher perceived quality of care (P = 0.02) in the intervention group. CONCLUSION: This holistic nurse-led self-management support intervention was found to be feasible and acceptable by professionals and recipients alike. This pilot had a small sample therefore further research is needed into the potential effects on self-management behavior and well-being of transplant recipients. ISRCTN Trial Registry: ISRCTN15057632 (registered retrospectively on 20-07-2018).

Patients' Expectations for Longevity of Kidney Transplant.

INTRODUCTION: Prior to transplantation, the transplant team is responsible for transplant education and posttransplant expectations. The majority of outcomes research focuses on 1- and 3-year graft survival, with a lack of literature focused upon whether patients have a realistic understanding of how many years deceased donor kidneys can be expected to function after transplant. OBJECTIVE: To determine whether potential kidney transplant patients' expectations for how long a deceased donor kidney will function after transplantation differs from transplant surgeons, using quantitative analysis. DESIGN: A cross-sectional survey was used with potential adult kidney transplant recipients and transplant surgeons. Patient surveys included demographics, quality-of-life questions, and questions of expectations of kidney function for deceased donor kidneys from the Kidney Donor Profile Index. The survey categorized donor organ risk as 0% to 20%, 21% to 85%, and 86% to 100%, and results were compared to responses from US Transplant Surgeons. Surgeons were contacted via e-mail using an online survey program. RESULTS: Responses included 154 transplant surgeons and 172 patients. Surgeon and patient responses were compared using Fisher exact test, showing a significant difference in each of the donor organ categories. We found that 47% of patient respondents did not correctly interpret the Kidney Donor Profile Index continuum. CONCLUSION: In every organ donor category, patients had a significantly different expectation for how long a transplanted kidney will last after transplant when compared to transplant surgeons. More study is required to determine why 47% of patients did not correctly interpret the Kidney Donor Profile continuum.

Effect of the iChoose Kidney decision aid in improving knowledge about treatment options among transplant candidates: A randomized controlled trial.

We previously developed a mobile- and web-based decision aid (iChoose Kidney) that displays individualized risk estimates of survival and mortality, for the treatment modalities of dialysis versus kidney transplantation. We examined the effect of iChoose Kidney on change in transplant knowledge and access to transplant in a randomized controlled trial among patients presenting for evaluation in three transplant centers. A total of 470 patients were randomized to standard transplantation education (control) or standard education plus iChoose Kidney (intervention). Change in transplant knowledge (primary outcome) among intervention versus control patients was assessed using nine items in pre- and postevaluation surveys. Access to transplant (secondary outcome) was defined as a composite of waitlisting, living donor inquiries, or transplantation. Among 443 patients (n = 226 intervention; n = 216 control), the mean knowledge scores were 5.1 ± 2.1 pre- and 5.8 ± 1.9 postevaluation. Change in knowledge was greater among intervention (1.1 ± 2.0) versus control (0.4 ± 1.8) patients (P < .0001). Access to transplantation was similar among intervention (n = 168; 74.3%) versus control patients (n = 153; 70.5%; P = .37). The iChoose Kidney decision aid improved patient knowledge at evaluation, but did not impact transplant access. Future studies should examine whether combining iChoose Kidney with other interventions can increase transplantation. (Clinicaltrials.gov NCT02235571).

The Benefit of Supplemental Nutrition Education for Severely Malnourished Patients Awaiting Liver Transplant.

INTRODUCTION: Nutritional interventions improve patient outcomes and reduce mortality in patients with cirrhosis by reducing infection risk, ascites, length of stay in hospital and intensive care unit, and mortality. Follow-up phone calls have been found to be useful in improving patient adherence to therapy. PROBLEM: The purpose of this quality improvement project was to determine whether supplemental nutrition education would improve nutrition and outcomes among patients with cirrhosis who are undergoing a liver transplant evaluation. In addition, we sought to measure patient adherence with nutritional recommendations and whether patients perceived this additional education improved their nutrition status. METHODS: The Plan-Do-Study-Ask methodology was used. PROCESSES: Addressed 8 patients were enrolled to participate in the supplemental nutrition education, after which they received 3 follow-up phone calls. A retrospective review of data from 10 patients meeting project inclusion criteria were identified by the nutrition specialist and were used as a comparison group. Data were analyzed using descriptive statistics; comparing data from before and after implementation of the supplemental nutrition education was done. OUTCOMES: At the end of the 8-week project period, 4 (66.7%) patients reported weight loss since the time of enrollment (nutrition education class), and the median patient-generated subjective global assessment score increased by 4 points, rather than decreasing as expected. However, all patients reported they believed the phone calls improved their nutrition status. IMPLICATIONS: With a multidisciplinary approach, this additional patient education may improve patient care and outcomes.

Multimedia Education Reduces Anxiety in Lung Transplant Patients.

CONTEXT: A significant contribution to the success of lung transplantation is the recipient's ability to self-manage a multidrug regimen and follow complex instructions. Effective education has always been an integral component of the process of preparing patients to care for themselves post lung transplant. Impaired cognition, anxiety, and psychological distress, however, can decrease the retention of posttransplant care information provided during education sessions. OBJECTIVE: This quality improvement project evaluated whether a multimedia education method compared to standard education method improves posttransplant care knowledge, anxiety, and satisfaction with the education experience in lung transplant patients and their caregivers. METHODS: Two education methods groups, comprised of transplant patients and their primary caregivers, were compared: (1) historic control group who received the standard education (n = 19 dyads) and (2) multimedia group who received the new multimedia education (n = 18 dyads). Knowledge of posttransplant care was evaluated in both groups before and after receiving the education. A satisfaction survey was administered at the end of the education program. RESULTS: A significantly higher percentage of patients receiving the multimedia method reported gains in posttransplant care knowledge ( P = .05), less anxiety about the transplant surgery ( P = .02), and satisfaction with the education method ( P = .02) when compared to those receiving the standard method. Caregivers and transplant team member also indicated that the multimedia method was more effective than the standard method. CONCLUSION: Multimedia methods decrease anxiety and increase satisfaction with the education experience when preparing patients for lung transplantation.

A Multimodal Skin Cancer Prevention Program for Heart Transplant Patients.

BACKGROUND: Immunosuppressant medications are essential for long-term survival following transplantation but increase the risk of developing skin cancer. Prevention and early detection of skin cancer requires screening and sun protection behaviors that can be achieved with patient education. PROBLEM STATEMENT: Our method for educating post heart transplant patients regarding skin cancer was inconsistent and was not effective. The aim of this project was to develop and integrate a multimodal skin cancer education program to increase knowledge and protective behaviors for heart transplant recipients. METHODS: Twenty-five post heart transplant patients who were scheduled to be seen for routine posttransplant care at a single-center transplant center between October 26, 2016, and November 15, 2016, took part in a multimodal skin cancer education program. RESULTS: There was a significant increase in knowledge between pretest and posttest 1 ( P <.01) and pretest and posttest 2 ( P <.01). A significant increase in sun protective behavior was noted. The project noted that knowledge and behavior was retained, knowledge score posttest 1 to posttest 2 ( P = .085), all had seen a dermatologist or had an appointment scheduled, and self skin exam retention was noted between posttest 1 and posttest 2 ( P = .25). Process Addressed: The feasibility of and findings from this intervention have led the clinic team to implement this protocol as part of the standard care for all patients. CONCLUSIONS: These data suggests that a multimodal intensive skin cancer education program may be effective at increasing knowledge and protective behavior with heart transplant recipients.

Cultural competency of a mobile, customized patient education tool for improving potential kidney transplant recipients' knowledge and decision-making.

Patients considering renal transplantation face an increasingly complex array of choices as a result of the revised kidney transplant allocation system. Decision aids have been shown to improve patient decision-making through the provision of detailed, relevant, individualized clinical data. A mobile iOS-based application (app) including animated patient education and individualized risk-adjusted outcomes following kidney transplants with varying donor characteristics and DSA waiting times was piloted in two large US transplant programs with a diverse group of renal transplant candidates (N = 81). The majority (86%) of patients felt that the app improved their knowledge and was culturally appropriate for their race/ethnicity (67%-85%). Patients scored significantly higher on transplant knowledge testing (9.1/20 to 13.8/20, P < .001) after viewing the app, including patients with low health literacy (8.0 to 13.0, P < .001). Overall knowledge of and interest in living and deceased donor kidney transplantation increased. This pilot project confirmed the benefit and cultural acceptability of this educational tool, and further refinement will explore how to better communicate the risks and benefits of nonstandard donors.

Education Before Kidney Transplantation.

CONTEXT: Poor knowledge about immunosuppressive (IS) medications remains a major problem for patients in the posttransplant setting. Therefore, more effective educational strategies in the pretransplant setting are being considered as a possible method to improve knowledge and readiness for the challenges of posttransplant care. However, the most effective/relevant content of a pretransplant educational program is yet to be determined. OBJECTIVE: To identify pretransplant education topics from the posttransplant patient perspective. DESIGN: A focus group meeting was conducted among 7 high-functioning, stable adult kidney transplant recipients recruited from the Saskatchewan Transplant Program. Demographic information including age, gender, occupation, background/ethnicity, and time since transplant were recorded. A moderator, assistant moderator, and research assistant facilitated the 90-minute focus group meeting using a predetermined semistructured interview guide. The session was audio recorded and transcribed verbatim. Nvivo software was used to code the data and identify emerging themes exploring views of participants relating to the educational information required for pretransplant patients. RESULTS: Patients were satisfied with the education they had received. Ideas were classified into the following major themes-patient satisfaction, transplant waitlist, surgery, medications, posttransplant complications, lifestyle and monitoring, knowledge acquisition, illusion of control, and life changes posttransplant. Knowledge gaps were identified in all areas of the transplantation process and were not exclusive to IS medications. CONCLUSION: Misconceptions regarding transplantation were identified by a group of high-functioning, stable adult recipients who were satisfied with their clinical care. Future educational strategies should aim to address the entire transplantation process and not be limited to medications.

A Clustered Randomized Trial of an Educational Intervention During Transplant Evaluation to Increase Knowledge of Living Donor Kidney Transplant.

INTRODUCTION: Maximizing education about living donor kidney transplant (LDKT) during the in-person evaluation at the transplant center may increase the numbers of kidney patients pursuing LDKT. Research Questions and Design: To test the effectiveness of a 1-time LDKT educational intervention, we performed a cluster-randomized trial among 499 patients who presented for evaluation of kidney transplant. We compared usual care education (n = 250) versus intensive LDKT education (n = 249), which was implemented only on the evaluation day and consisted of viewing a 25-minute video of information and stories about LDKT and discussion of LDKT possibilities with an educator. Our primary outcome was knowledge of LDKT, 1 week after the transplant evaluation. RESULTS: One week after evaluation, patients who received intensive education had higher knowledge than patients who received usual care (12.7 vs. 11.7; P = .0008), but there were no differences in postevaluation readiness for LDKT. Among patients who had not previously identified a potential living donor, receiving intensive education was associated with increased willingness to take steps toward LDKT. DISCUSSION: In conclusion, expansion of LDKT education within the evaluation day may be helpful, but interventions that are implemented at multiple times and for greater duration may be necessary to ensure larger and long-term behavioral changes in pursuit of LDKT.

Sun protection education for diverse audiences: need for skin cancer pictures.

Sun protection education is needed for kidney transplant recipients, whose increased risk of skin cancer could be ameliorated with sun protection. Cognitive interviews with 24 participants equally stratified among non-Hispanic White, non-Hispanic Black, and Hispanic/Latino kidney transplant recipients were performed to evaluate a sun protection education workbook. Study participants were recruited over the phone using a registry of 700 kidney transplant recipients. Participants included 12 women and 12 men with a median age of 52. In 16 of the cognitive interviews with non-Hispanic Blacks and Hispanic/Latinos, pictures of skin cancer were requested by the participants in order to see the appearance of skin cancer. Kidney transplant recipients with skin of color did not consider themselves at risk to develop skin cancer and wanted to see examples of skin cancer occurring on people with skin of color. Based on these results, the workbook was modified to include pictures of squamous cell carcinoma on varying skin tones. Then, 8 participants evaluated the revised workbook in cognitive interviews and found the photographs acceptable and necessary to demonstrate the severity of skin cancer and personalize their risk of developing skin cancer. The participants progressed from having knowledge of skin cancer to believing that they could develop skin cancer because they observed skin cancers on people with their skin tone. Using pictures of skin cancers occurring on people with similar skin tone may heighten a kidney transplant recipients' sense of vulnerability and possibly improve the use of sun protection.

Efficacy of a sun protection workbook for kidney transplant recipients: a randomized controlled trial of a culturally sensitive educational intervention.

A culturally sensitive educational intervention that encouraged sun protection behaviors among kidney transplant recipients (KTRs) was developed and the short-term efficacy was evaluated. Non-Hispanic White, Hispanic/Latino and non-Hispanic Black patients, who received a transplant 2-24 months prior to the study, were randomized into two study groups: intervention versus standard of care. Electronic reminders tailored to the weather conditions were sent every 2 weeks by text message or email. Self-reported surveys and biologic measurements were obtained prior to the intervention and 6 weeks later. Among the 101 study participants, there was a statistically significant increase in knowledge, recognition of personal risk of developing skin cancer, willingness to change sun protection behavior and self-reported performance of sun protection in participants receiving the intervention in comparison with those receiving standard of care (p < 0.05). The pigment darkening of the sun-exposed forearm and sun damage of the forearm and sunburns/skin irritation from the sun were significantly less in participants receiving the intervention (p < 0.05). Providing sun protection education at the beginning of summer with reminders tailored to weather conditions helped KTRs adopt sun protection practices. This sun protection program for KTRs may be incorporated into the care provided by the nephrologist or transplant surgeon.

Interpersonal Connections Are Important for Virtual Kidney Transplant Educational Program Development.

Introduction: The Living Donor Navigator program is designed to mitigate disparities in living donor kidney transplantation, although geographic disparities in program participation were observed in the initial years of implementation. The purpose of this study was to understand participant perspectives regarding the use of a virtual option/alternative to expand program participation. Methods: Previous participants of the in-person navigator program were purposively sampled. Using the nominal group technique, a well-structured formative methodology to elicit participant perspectives, 2 meetings were conducted among transplant recipients and advocates (N = 13) to identify and prioritize responses to the question "What things would concern you about participating in a virtual and remote Living Donor Navigator program?" Findings: Mean participant age was 59.3 (9.3) years, and participants were 54% male and 62% white. Education levels varied from less than high school to master's degrees. Participants generated 70 unique responses, of which 36 (51.4%) received prioritization. The top 5 ranked responses of each nominal group technique meeting received approximately 50 percent (47.6% vs. 66.7%, respectively) of the total votes and described the potentially limited interpersonal connections, time conflicts, and differing content in a virtual navigator program compared to the in-person model. Discussion: These data suggest that previous participants were concerned with upholding the original design of the program, thus, virtual living donor kidney transplantation programs should aim to maintain interpersonal connections and consistency of content to ensure adequate programmatic engagement. Future research will focus on program fidelity independent of delivery modality.

Principles of immunisation in children with solid organ transplant.

Vaccine-preventable diseases (VPD) are a significant risk to paediatric solid organ transplant (SOT) recipients on lifelong immunosuppressive therapy. Children progressing to end-stage organ dysfunction are unable to mount a robust immune response. Hence, it is important to plan vaccination early in the course of disease, especially if a child is anticipated to be a SOT candidate. Vaccine recommendations need to be individualised in this population based on vaccine history and serology. Catch-up or accelerated schedules may be used to complete vaccinations before transplant. Post-transplant, immunisation is recommenced in consultation with the transplant team taking into context the time since transplant and the intensity of the immunosuppressive regime. Inactivated vaccines are safe post-transplant but postexposure prophylaxis may still be required in children with inadequate immunity to VPD. Specific vaccines may be advised for SOT recipients travelling abroad (in consultation with a travel clinic) or those entering high-risk professions. Additionally, the vaccination status of all household members and close contacts should be reviewed and optimised, offering additional protection to the transplant recipient.

Contraceptive Choices and Counseling in Norwegian Female Renal Transplant Recipients.

BACKGROUND: There are major gaps in the understanding of sexual and reproductive health in female renal transplant recipients. METHODS: In this Norwegian multicenter retrospective observational study, 118 female renal transplant recipients aged 22 to 49 years responded to a questionnaire on fertility, contraceptive use, and pregnancy. RESULTS: More than one-third (37%) of patients reported that they did not receive advice on contraceptive methods from health care personnel in the early post-transplant phase. These women used effective contraceptive methods less often. Nearly half of the patients (45%) reported that they had not received any advice on timing of conception after transplant. From 95 pregnancies after renal transplant, 52 (55%) resulted in live births. CONCLUSION: Counseling on contraceptive methods should be part of standard care in conjunction with transplantation. More than one-third of young female renal transplant recipients of reproductive age could not recall having received advice from health care personnel about contraceptive use, and nearly half of the patients did not receive preconceptional advice after transplant. Although the current study does not discriminate between lack of advice and recall bias, the findings signal the need for improved counseling on female sexual and reproductive health after renal transplant.

Efficacy of Educational Interventions in Improving Measures of Living-donor Kidney Transplantation Activity: A Systematic Review and Meta-analysis.

BACKGROUND: To address patient-level barriers to living-donor kidney transplantation (LDKT), centers have implemented educational interventions. Recently, some have highlighted several gaps in knowledge and lack of evidence of efficacy of these interventions. No review has synthesized the available data. METHODS: We conducted a systematic review and meta-analysis of studies conducted to increase measures of LDKT. Outcomes of interest were LDKT rates, donor evaluation, donor contact/inquiry, total transplantation rates, and change in knowledge scores and pursuit behaviors. A literature search was conducted across 7 databases from inception until 2017. Educational interventions were a decision/teaching aid alone or with personalized sessions. Comparator was another intervention or nonspecific education. Random effects meta-analysis was performed to pool risk ratios (RRs) across studies. RESULTS: Of the 1813 references, 15 met the inclusion criteria; 9 were randomized control trials. When compared with nonspecific education, interventions increased LDKT rates (RR = 2.54; 95% confidence interval [CI], 1.49-4.35), donor evaluation (RR = 3.82; 95% CI, 1.91-7.64), and donor inquiry/contact (RR = 2.41; 95% CI, 1.53-3.80), but not total transplants (RR = 1.24; 95% CI, 0.96-1.61). Significant increased mean knowledge scores postintervention was noted, and most showed favorable trends in pursuit behaviors. Quality across the studies was mixed and sometimes difficult to assess. The biggest limitations were small sample size, selection bias, and short follow-ups. CONCLUSIONS: Educational interventions improve measures of LDKT activity; however, current literature is heterogeneous and at risk of selection bias. Prospective studies with diverse patient populations, longer follow-ups, and robust outcomes are needed to inform clinical practice.

Assessment of Diabetes Knowledge Among Renal Transplant Recipients With Posttransplant Diabetes Mellitus: Kuwait Experience.

OBJECTIVES: Diabetes knowledge among kidney transplant recipients with posttransplant diabetes has not been exhaustively assessed. We evaluated levels of diabetes knowledge among our kidney transplant patients using a 35-item diabetes self-care management questionnaire. MATERIALS AND METHODS: The study comprised renal transplant patients with posttransplant diabetes mellitus who were referred from Hamed Al-Essa Organ Transplant Center of Kuwait to the Dasman Diabetes Institute. Patient data were collected through patient identification forms, metabolic control parameters forms, and diabetes self-care scale questionnaires (with score from 0-7). RESULTS: Of 356 (25.6%) kidney transplant recipients with posttransplant diabetes, 210 patients were enrolled in this study. Most were Kuwaiti (60%), men (48.8%), and with high school education level (43.8%). Some were smokers (11.9%), and the original kidney disease was glomerulonephritis in 37.6% of patients. Most patients (71.9%) received hemodialysis pretransplant. Most patients (> 88%) reported low mean score of healthy diet (0-3), with > 93% reporting low mean score of practicing exercise (0-3), > 62% not checking blood sugar at home, 85% not following the recommended frequency, and > 72% not caring for their feet (except washing in 86.7%). Moreover, most patients lacked information about sharp disposal, diet regimen, using logbooks, hypoglycemia and hyperglycemia, sick day management, and the importance of hemoglobin A1c and regular fundus examination. Mean score of practicing exercise was significantly higher in men (especially non-Kuwaiti; P < .05); otherwise, other mean scores were comparable between sexes and different nationalities (P > .05). CONCLUSIONS: Diabetes knowledge is deficient in patients with posttransplant diabetes. Seminars, counseling sessions, and workshops should be arranged periodically for renal transplant recipients to improve their low level of diabetes knowledge. This is a preliminary report of our randomized controlled study evaluating the impact of structured diabetes education on self-care activities and metabolic control variables.

Development of antibody mediated rejection shortly after acute cellular rejection in a pediatric kidney transplantation recipient.

Acute rejection is a major cause of graft loss in patients with kidney transplantations. However, the appropriate timing for performing a biopsy is often difficult to gauge in a clinical settings. We encountered an 8-year-old boy in whom antibody mediated rejection (AMR) associated with de novo donor-specific antibody (DSA) developed shortly after an episode of type IA acute cellular rejection (ACR). He had received a preemptive ABO-compatible kidney transplantation due to bilateral renal hypoplasia. Type IA ACR developed 2 months after transplantation and was successfully treated with methylprednisolone pulse therapy (MPT) and gusperimus hydrochloride. However, 4 months after transplantation, his serum creatinine level increased again. We decided to perform an additional biopsy despite having done the previous biopsy only a short time ago. Marked infiltration of inflammation cells in the peritubular capillaries (PTCs) with positive C4d staining was observed. AMR associated with de novo DSA with type IB ACR was newly diagnosed because DSA was not detected and the crossmatch test was negative before transplantation. He immediately received two courses of plasma exchange (PE), three courses of MPT, and rituximab. He confessed to non-adherence and underwent a patient education program with his family again. To date, no cases of AMR associated with de novo DSA shortly after ACR have been reported. Our experience lends support to the 'episode biopsy' method in which a biopsy is performed for each episode of serum creatinine increase as recommended by The Kidney Disease: Improving Global Outcomes (KDIGO) Transplant Working Group.