A Survey of Nephrologists Regarding Their Communication with Transplant Centers.

BACKGROUND: Patients with end-stage renal disease (ESRD) undergo a transition of care between their primary nephrologist and the transplant center during evaluation for kidney transplantation. Due to medical complexity, high hospitalization rate, and involvement of multiple medical stakeholders, transitions of medical care among patients with ESRD are likely to be associated with suboptimal care and medical errors. Provider-to-provider communication improves outcomes among ESRD patients transitioning between dialysis and transplant. There is little data analyzing proper transition of care between the nephrologist and the transplant center (TC). OBJECTIVE: Using survey methodology, we examined nephrologists' current practice and experience regarding patient-related communication with the TC. METHODS: From among 822 nephrologists who were following at least 20 ESRD patients, we randomly selected 252 nephrologists to participate in the study. The survey consisted of 102 multiple choice and Likert-style items probing perceptions about various aspects of transplant, including communication between TC and nephrologist. Responses from 216 participants who submitted complete responses were included in the final analysis. RESULTS: Depending on the phase of transplant, nephrologist-TC communication varied between 50%-81% of nephrologists. Factors associated with higher likelihood of nephrologist-TC communication included attending transplant-related educational activity, practicing in a group with more than 5 nephrologists, and having more than 50 patients on dialysis. The majority of nephrologists indicated satisfaction with access to an attending physician in the TC, receiving timely and adequate information from the TC about their patients. Factors associated with higher likelihood of nephrologist satisfaction regarding communication with the TC included attending national nephrology meetings, medical directorship of a dialysis unit, fellowship training at an institution with an on-site transplant program, and availability of more than 2 transplant centers within 50 miles. CONCLUSION: There is a lack of evidence-based guidelines for patient transfer of care between nephrologists and transplant centers during various phases of transplant referral, evaluation and post-transplant care. We found that the likelihood of the nephrologists' communication with the transplant center and their satisfaction with the communication are related to their training, participation in continuing educational meetings, their practice location and size, and the overall composition of their patient population.

Factors Considered by Nephrologists in Excluding Patients from Kidney Transplant Referral.

BACKGROUND: Provider perceptions about patient candidacy for kidney transplant (KT) are potentially significant contributors to disparities in KT. OBJECTIVE: To examine nephrologists' perceptions about factors that are important in excluding patients from KT referral, and to analyze the association between these perceptions and nephrologists' demographic and practice characteristics.Methods: Invitations were sent to 3180 nephrologists. Among those who consented, 822 fulfilled the inclusion criteria, and 250 were randomly invited to complete a questionnaire about perceptions of factors essential in deciding not to refer patients for KT. RESULTS: Responses from 216 participants with complete responses were analyzed. The 3 most common reasons for excluding patients were "patient's inadequate social support" (44%), "limited understanding of the process due to patient's inadequate education" (32%), and "patient's age above 65" (26%). Nephrologists practicing in rural settings were more likely to consider inadequate support and limited education of patients as reasons not to refer for KT. In multivariate analysis, physicians with 2 or fewer transplant centers within 50 miles were more likely to report inadequate social support (OR: 3.15, 95% CI: 1.59-6.24) and age greater than 65 years (OR: 1.88, 95% CI: 1.01-3.49) as reasons to exclude patients from KT referral. Nephrologists whose practice included patients majority of whom had not completed high school were more likely to consider limited understanding due to inadequate education as an important reason to exclude patients from KT (OR: 3.31, 95% CI: 1.60-6.86). CONCLUSION: Patient's social support, understanding, and age were the most common factors regarded by nephrologists as important in not referring patients for KT evaluation. Practice location, particularly rural setting, proximity to a transplant center, and the education level of a nephrologist's patient population were important determinants of referral for KT.

Perioperative use of continuous renal replacement therapy for orthotopic liver transplantation.

PURPOSE: We present a retrospective study describing the perioperative use of continuous renal replacement therapy (CRRT) for orthotopic liver transplantation (OLT). MATERIALS AND METHODS: We retrospectively reviewed the clinical course of patients who underwent OLT with the perioperative use of CRRT. The following variables were recorded: Gender, age, indication for transplantation, time when CRRT was initiated, postoperative need for CRRT, and the patient and organ (liver, kidneys) outcome up to 1 year after transplantation. RESULTS: Among 105 patients who underwent OLT from 2006 to 2010; we used CRRT in 12 cases (11.4%) perioperatively, including 9 (8.3%) patients intraoperatively. Perioperative CRRT was employed for volume, electrolyte, and/or pH management. All patients who underwent CRRT perioperatively were alive at 1 month, 10 (83.3%), at 3 and 6 months and 9 (75%) at 1 year after OLT. Only 1 surviving patient (8.3%) required renal replacement therapy at 1 month after surgery. Renal replacement therapy was not required in any surviving patient up to 12 months posttransplantation. CONCLUSION: Perioperative and especially intraoperative use of CRRT therapy can potentially improve the outcomes of patients undergoing OLT.

A Systematic Review and Meta-analysis of Prophylactic versus Pre-emptive Strategies for Preventing Cytomegalovirus Infection in Renal Transplant Recipients.

BACKGROUND: In kidney transplant (KT) recipients, CMV infection poses significant morbidity and mortality. Both prophylactic and pre-emptive approaches for preventing CMV infection have been utilized. OBJECTIVE: To compare the effectiveness of routine prophylaxis vs. pre-emptive treatment for preventing CMV disease after KT. METHODS: We conducted a systematic review and meta-analysis comparing the effectiveness of routine prophylaxis vs. pre-emptive treatment for preventing CMV disease after KT. Combining 4 comprehensive search terms (CMV, renal transplant, prophylaxis, pre-emptive); we searched PubMed, EMBASE, ISI Web of Science, and Cochrane Central Register from inception through January 2011. We also evaluated studies referenced in review articles and abstracts from meetings of major nephrology and transplant societies (2009-2011). Two authors independently extracted data and assessed methodological criteria. The primary outcome was the pooled estimate of the odds ratio (OR) of developing CMV infection. Secondary outcomes included OR of acute rejection, OR of graft loss and OR of death within first year of KT. Comprehensive Meta-analysis V2 software was used for data analysis. RESULTS: Analysis of 9 randomized controlled trials (991 patients; ganciclovir=5, valganciclovir=4) with CMV infection as an outcome revealed the OR of CMV infection to be 0.34 (95% CI: 0.25-0.46, p=0.008) for the prophylactic vs. the pre-emptive groups. The OR of acute rejection (7 studies; 1358 patients) was 0.52 (95% CI: 0.41-0.67, p=0.001) with prophylactic approach compared to pre-emptive treatment; graft loss (7 studies; OR 0.52 [95% CI: 0.34-1.12, p=0.32] and mortality (6 studies; OR 0.84 [95% CI: 0.62-1.23, p=0.23]) were similar between the two groups. CONCLUSIONS: Prophylactic approach is superior to pre-emptive approach in preventing CMV infection within the first year of kidney transplant. The risk of developing acute rejection is also lower with prophylactic approach in the first year of transplant but there is no significant difference in graft loss or mortality with either approach.

A Systematic Review and Meta-Analysis of Rituximab in Antibody-mediated Renal Allograft Rejection.

BACKGROUND: The standard treatment of antibody-mediated rejection (AMR) consists of antilymphocyte antibody, intravenous immunoglobulin, and plasmapheresis. This treatment is associated with a high rate of resistance and refractory AMR. Recent interest has focused on use of rituximab (RTX), a chimeric anti-CD20 monoclonal antibody. OBJECTIVE: We conducted a systematic review and meta-analysis of studies of RTX in AMR of the renal allograft. METHODS: Combining two comprehensive search themes (AMR and RTX), we searched electronic databases from 1969 through 2010, supplemented by a manual review of abstracts from nephrology and transplant meetings, and reference lists of review articles. All studies evaluating explicit response of patients with AMR to RTX were included. The outcome was pooled odds ratio (OR) of response to RTX. RESULTS: A total of 114 studies were identified, 94 of which were excluded on initial screening. Analysis of the 10 studies (249 patients) showed an OR of 3.16 (95% CI: 1.75-5.70) for response to RTX. Reported adverse effects included BK virus nephropathy, cytomegalovirus (CMV) viremia, pneumonia, herpes zoster, and septic shock. CONCLUSION: This study suggests that RTX is a reasonable therapeutic option in the treatment of AMR. Further randomized studies are necessary to establish its efficacy and safety.

Living organ donation: an ethical evolution or evolution of ethics?

The disparity between available and needed organs is rapidly increasing, and the number of patients dying while still on the waiting list is growing exponentially. As a partial solution to this disparity, living unrelated transplantation is being performed more frequently, and some have proposed providing financial incentives to donors. The aim of this discussion is to illustrate that with an ever-increasing number of living unrelated transplantations, society and the transplant community should adopt a more active role in developing specific strategies to scrutinize the process. The current paper will also examine the viewpoint that medical ethics is not separable from the prevailing needs of society and involves a constant balancing of often opposing goods. Issues surrounding living unrelated donor transplantation illustrate ethics as a dynamically evolving field, which is often influenced by necessity and which evolves with progression of science and society. As part of this evolution, it is the collective responsibility of society and the transplant community to devise safeguards to guarantee adherence to basic principles of ethics and to avoid "situational ethics."

Silica nephropathy.

Occupational exposure to heavy metals, organic solvents and silica is associated with a variety of renal manifestations. Improved understanding of occupational renal disease provides insight into environmental renal disease, improving knowledge of disease pathogenesis. Silica (SiO2) is an abundant mineral found in sand, rock, and soil. Workers exposed to silica include sandblasters, miners, quarry workers, masons, ceramic workers and glass manufacturers. New cases of silicosis per year have been estimated in the US to be 3600-7300. Exposure to silica has been associated with tubulointerstitial disease, immune-mediated multisystem disease, chronic kidney disease and end-stage renal disease. A rare syndrome of painful, nodular skin lesions has been described in dialysis patients with excessive levels of silicon. Balkan endemic nephropathy is postulated to be due to chronic intoxication with drinking water polluted by silicates released during soil erosion. The mechanism of silica nephrotoxicity is thought to be through direct nephrotoxicity, as well as silica-induced autoimmune diseases such as scleroderma and systemic lupus erythematosus. The renal histopathology varies from focal to crescentic and necrotizing glomerulonephritis with aneurysm formation suggestive of polyarteritis nodosa. The treatment for silica nephrotoxicity is non-specific and depends on the mechanism and stage of the disease. It is quite clear that further research is needed, particularly to elucidate the pathogenesis of silica nephropathy. Considering the importance of diagnosing exposure-related renal disease at early stages, it is imperative to obtain a thorough occupational history in all patients with renal disease, with particular emphasis on exposure to silica, heavy metals, and solvents.