Living Kidney Donors' Financial Expenses and Mental Health.

BACKGROUND: Living kidney donors incur donation-related expenses, but how these expenses impact postdonation mental health is unknown. METHODS: In this prospective cohort study, the association between mental health and donor-incurred expenses (both out-of-pocket costs and lost wages) was examined in 821 people who donated a kidney at one of the 12 transplant centers in Canada between 2009 and 2014. Mental health was measured by the RAND Short Form-36 Health Survey along with Beck Anxiety Inventory and Beck Depression Inventory. RESULTS: A total of 209 donors (25%) reported expenses of >5500 Canadian dollars. Compared with donors who incurred lower expenses, those who incurred higher expenses demonstrated significantly worse mental health-related quality of life 3 months after donation, with a trend towards worse anxiety and depression, after controlling for predonation mental health-related quality of life and other risk factors for psychological distress. Between-group differences for donors with lower and higher expenses on these measures were no longer significant 12 months after donation. CONCLUSIONS: Living kidney donor transplant programs should ensure that adequate psychosocial support is available to all donors who need it, based on known and unknown risk factors. Efforts to minimize donor-incurred expenses and to better support the mental well-being of donors need to continue. Further research is needed to investigate the effect of donor reimbursement programs, which mitigate donor expenses, on postdonation mental health.

Financial Costs Incurred by Living Kidney Donors: A Prospective Cohort Study.

BACKGROUND: Approximately 40% of the kidneys for transplant worldwide come from living donors. Despite advantages of living donor transplants, rates have stagnated in recent years. One possible barrier may be costs related to the transplant process that potential willing donors may incur for travel, parking, accommodation, and lost productivity. METHODS: To better understand and quantify the financial costs incurred by living kidney donors, we conducted a prospective cohort study, recruiting 912 living kidney donors from 12 transplant centers across Canada between 2009 and 2014; 821 of them completed all or a portion of the costing survey. We report microcosted total, out-of-pocket, and lost productivity costs (in 2016 Canadian dollars) for living kidney donors from donor evaluation start to 3 months after donation. We examined costs according to (1) the donor's relationship with their recipient, including spousal (donation to a partner), emotionally related nonspousal (friend, step-parent, in law), or genetically related; and (2) donation type (directed, paired kidney, or nondirected). RESULTS: Living kidney donors incurred a median (75th percentile) of $1254 ($2589) in out-of-pocket costs and $0 ($1908) in lost productivity costs. On average, total costs were $2226 higher in spousal compared with emotionally related nonspousal donors (P=0.02) and $1664 higher in directed donors compared with nondirected donors (P<0.001). Total costs (out-of-pocket and lost productivity) exceeded $5500 for 205 (25%) donors. CONCLUSIONS: Our results can be used to inform strategies to minimize the financial burden of living donation, which may help improve the donation experience and increase the number of living donor kidney transplants.

Evaluating the accuracy of functional biomarkers for detecting histological changes in chronic allograft nephropathy.

The most common cause of late kidney transplant failure is chronic allograft nephropathy (CAN). Much research has focused on identifying biomarkers (or correlates) that would predict subsequent CAN and allow timely intervention. Functional biomarkers such as serum creatinine and estimated glomerular filtration rate (eGFR) have been widely adopted, even though they have not been rigorously evaluated as surrogate markers. This study evaluated serum creatinine and eGFR for predicting the early histopathological changes seen in transplant protocol biopsies (TPB). We prospectively followed 289 kidney transplant patients in the Southern Alberta Transplant Program who had TPB at 6-12 months post-transplant. Tissue samples (n = 280) were independently examined by renal pathologists. The ability of serum creatinine or eGFR to predict the threshold level for abnormal histopathology was evaluated by calculating the area under the receiver operator characteristic curve. Serum creatinine and eGFR had poor predictive value (most confidence intervals included 0.5, indicating no predictive ability) for ten individual histological measurements (Banff 97 scores), and the Chronic Allograft Damage Index. We conclude that serum creatinine and eGFR have a limited clinical role in predicting the early histopathological changes that precede CAN and should not be used for this purpose.

Clinical predictors of renal allograft histopathology: a comparative study of single-lesion histology versus a composite, quantitative scoring system.

BACKGROUND: Progressive injury that is refractory to conventional immunosuppression remains the major hurdle to indefinite survival of transplanted organs. Several clinical risk factors of chronic renal allograft rejection have been identified; although some (e.g., acute rejection) are direct manifestations of immunological injury, others (e.g., donor age) have been more difficult to conceptually link with graft dysfunction. METHODS: We conducted formal multivariate statistical analyses to reveal associations between established clinical risk factors and allograft histopathology. In a multicenter protocol biopsy-controlled study, 17 clinical risk factors were studied in relation to either the composite Chronic Allograft Damage Index (CADI) score or, to each of eight individual histological indices, using multiple linear regression with forward selection. RESULTS: Nine clinical risk factors were not significantly associated with any histopathological index. Four (donor age, acute rejection, recipient age, and cold ischemia time) were associated both with the total CADI score and, to varying extents, with the individual histopathological indices. In our analysis, clinical risk factors accounted for, at best, only about 60% of the interindividual variation in histopathological score. CONCLUSIONS: Our study reveals a missing link between specific clinical risk factors and early histopathological findings that are known to presage accelerated failure of clinically healthy grafts. Given the complex relationship between clinical risk factors, early histopathological changes, and graft outcome, we conclude that composite, quantitative histological indices are best suited to for evaluation of the histological status of the transplant.

Renal allograft compartment syndrome: an underappreciated postoperative complication.

PURPOSE: Renal allograft compartment syndrome (RACS) is early graft dysfunction secondary to retroperitoneal hypertension and resultant ischemia. Our purpose was to identify the incidence, therapies and outcomes of patients with RACS. METHODS: All patients who underwent a renal transplant between 2000 and 2005 were reviewed. Patients with signs of acute allograft dysfunction were identified. RACS was diagnosed via visual allograft hypoperfusion and/or with preoperative Doppler ultrasound. RESULTS: Among 458 patients, 11 (2%) were diagnosed with RACS. Characteristics between patient groups were similar. Five (45%) patients displayed adequate initial allograft function after transplantation. Doppler ultrasound was diagnostic. Six (55%) patients displayed poor initial allograft function and were classified as early presenters of RACS. Allograft function improved dramatically upon decompression. CONCLUSIONS: Clinicians must remain aware of RACS as a potential diagnosis when patients display rapid deterioration in kidney performance after good initial allograft function. Doppler ultrasound is useful in diagnosing late presenters.

Cirgugía torácica videoasistida: experiencia con 114 casos

Objetivo. Describir la experiencia de los autores con lo sprocedimientos de cirugía torácica videoasistida (CTVA) en 4 instituciones de Santa Fe de Bogotá. Diseño. Estudio observacional descriptivo. Material y métodos. Se revisaron las historias de 114 pacientes sometidos a CTVA, las indicaciones, técnicas quirúrgicas, procedimientos, complicaciones y mortalidad. Se describe la tasa de conversión a cirugía abierta y las indicaciones para realizar dicha conversión.Resultados. Ciento catorce pacientes fueron incluídos en el estudio (64 hombre y 50 mujeres). La edad promedio fue de 62 años (rango de 16 a 89). En todos los procedimientos se utilizó anestesia general con ventilación selectiva de un solo pulmón, sin insuflación de CO2. Las indicaciones de los procedimientos de CTVA fueron las siguientes: nódulo pulmonar indeterminado en 49 pacientes (42.9 por ciento), infiltrados pulmonares en 20 (17.5 por ciento), neumotórax espontáneo en 22 (19.2 por ciento), derrames pleurales en 16 (14 por ciento), masas del mediastino en 4 (3.5 por ciento) y masas pleurales en 3 (2.6 por ciento). Se practicaron 133 procedimientos: resecciones en cuña en 69 pacientes, resecciones en cuña y pleurodesis mecánica en 16, plicatura de bulas y pleurectomía limitada en 6, biopsias pleurales en 17, pleurodesis con talco en 13, resección de masas del mediastino en 4, resección de tumores pleurales en 2 y biopsias de ganglios hiliares o del mediastino en 6. La tasa de conversión a cirugía abierta fue del 18.5 por ciento. Las causas más frecuentes para la concersión fueron la resección de una lesión maligna y la remoción de nódulos profundos. La tasa de mortalidad fue del 1.7 por ciento. Se presentaron las siguientes complicaciones en 13 pacientes (11.4 por ciento): escape prolongado de aire en 5, fibrilación auricular en 3, neumonía en 2, empiema en 1, insuficiencia respiratoria en 1 y hemorragia en 1. El tiempo promedio de hospitalización fue de 5 días. Conclusión. La Ctva es un método seguro y útil para el tratamiento de algunas enfermedades torácicas. Recomendamos la conversión a cirugía abierta cuando se trata de resecar lesiones malignas