ABSTRACT
This article will discuss diagnostic stewardship from the perspective of those who are just starting, or have recently started, a diagnostic stewardship effort. This document will provide guidance on how to identify opportunities for intervention and tools that can be used to affect change. Specifically, we will discuss key components of a diagnostic stewardship committee, referral laboratory testing, prior authorization, miscellaneous test orders, establishing a laboratory test formulary, and conclude with some specific examples of interventions that can be considered.
Subject(s)
Clinical Laboratory Services , Laboratories, ClinicalABSTRACT
Prior studies on belatacept conversion from calcineurin inhibitor (CNI) have been limited by an absence of postconversion surveillance biopsies that could underestimate subclinical rejection, or a case-controlled design. A total of 53 adult patients with allograft dysfunction underwent belatacept conversion (median: 6 months) post-transplant. At a median follow-up = 2.5 years, patient survival was 94% with a death-censored graft survival of 85%. Seven (13%) patients had acute rejection (including 3 subclinical) at median 6 months postconversion. Overall, eGFR improved (P = <0.001) from baseline = 31±15 to 40.2 ± 17.6 ml/min/1.73m2 by 6 months postconversion, but then stayed stable. This improvement was also observed (P < 0.001) in comparison with a propensity matched control cohort on CNI, where eGFR stayed stable (mean ~ 32ml/min/1.72m2 ) over 2-year follow-up. Patients converted < 6 months post-transplant were more likely to have a long-term improvement in kidney function. Paired gene expression analysis of 30 (of 53) consecutive pre- and postconversion surveillance biopsies did not reveal changes in inflammation/acute injury; although atrophy-fibrosis score worsened (mean = 0.28 to 0.44; P = 0.005). Thus, improvement in renal function with belatacept conversion occurred early and then sustained in comparison with controls where renal function remained unchanged overtime. We were unable to show molecular signals that could be related to CNI administration and regressed after withdrawal.
Subject(s)
Kidney Transplantation , Abatacept , Adult , Calcineurin Inhibitors , Gene Expression , Graft Rejection , Graft Survival , Humans , Immunosuppressive AgentsABSTRACT
In this integrative review, current research on the effectiveness of intravenous (IV) securement devices is described and practical implications for evidence-based practice in IV care are provided.
