RESUMEN
Recent reports suggest that bridge-donor reneging is rare (1.5%) in non-simultaneous kidney exchange chains. However, in developing countries, the non-directed donors who would be needed to initiate chains are unavailable, and furthermore, limited surgical space and resources restrain the feasibility of simultaneous kidney exchange cycles. Therefore, the aim of this study was to evaluate the bridge-donor reneging rate during non-simultaneous kidney exchange cycles (NSKEC) in a prospective single-center cohort study (n = 67). We describe the protocol used to prepare co-registered donor-recipient pairs for non-simultaneous surgeries, in an effort to minimize the reneging rate. In addition, in order to protect any recipients who might be left vulnerable by this arrangement, we proposed the use of standard criteria deceased-donor kidneys to rectify the injustice in the event of any bridge-donor reneging. We report 17 successful NSKEC resulting in 67 living-donor kidney transplants (LDKT) using 23 bridge-donors without donor renege and no intervening pairs became unavailable. We propose that NSKEC could increase LDKT, especially for difficult-to-match sensitized pairs (25 of our 67 pairs) in countries with limited transplantation resources. Our study confirms that NSKEC can be safely performed with careful patient-donor selection and non-anonymous kidney exchanges.
Asunto(s)
Donadores Vivos , Obtención de Tejidos y Órganos , Sistema del Grupo Sanguíneo ABO , Estudios de Cohortes , Selección de Donante , Humanos , Riñón , Estudios ProspectivosRESUMEN
We examined what happened during a 6-year period to 1121 end-stage renal disease patients who registered with their willing/incompatible living donors for kidney exchanges with the Alliance for Paired Donation (APD). Of all patients, 65% were transplanted: 37% in kidney paired donation (APD-KPD, APD-other-KPD); 10% with compatible live donors (APD-LD); and 18% with deceased donors (APD-DD). The remaining patients were withdrawn (sick/died/others; 15%), or were still waiting (20%). For those patients with a cPRA 0-94%, 72% received a transplant. In contrast, only 49% of very highly sensitized (VHS; cPRA 95-100%) were transplanted. Of the VHS patients, 50% were transplanted by KPD/APD-LD while 50% benefited through prioritization of deceased donors in the modified kidney allocation system (KAS introduced in 2014). All APD transplanted groups had similar death-censored 4-year graft survivals as their relevant Organ Procurement and Transplantation Network (OPTN) groups. It is noteworthy that VHS graft and patient survival results were comparable to less sensitized and nonsensitized patients. All patients should be encouraged to search for compatible donors through different options. Expanding the donor pool through KPD and the new KAS of the OPTN increases the likelihood of transplantation for VHS patients.
Asunto(s)
Fallo Renal Crónico/cirugía , Trasplante de Riñón/métodos , Obtención de Tejidos y Órganos/métodos , Adulto , Algoritmos , Bases de Datos Factuales , Salud de la Familia , Femenino , Supervivencia de Injerto , Humanos , Donadores Vivos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del Tratamiento , Estados UnidosRESUMEN
BACKGROUND: Global Kidney Exchange (GKE) offers an opportunity to expand living renal transplantation internationally to patients without financial means. These international pairs are entered into a US kidney exchange program that provides long-term financial support in an effort to identify opportunities for suitable exchanges for both these international pairs and US citizens. OBJECTIVE: While the promise of GKE is significant, it has been met with ethical criticism since its inception in 2015. This paper aims to demonstrate the selection process and provide >3 yr of follow-up on the first GKE donor and recipient from the Philippines. DESIGN, SETTING, AND PARTICIPANTS: The first GKE transplant occurred with a young Filipino husband and wife who were immunologically compatible, but lacked the financial means to continue hemodialysis or undergo a kidney transplant in their home country. The pair was enrolled in the Alliance for Paired Donation matching system, several alternative kidney exchanges were identified, and the pair subsequently underwent renal transplantation and donation in the USA financed by philanthropy. The resulting nonsimultaneous extended altruistic chain provided transplantation for the Filipino husband and 11 US patients. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The Filipino donor and recipient were followed by transplant professionals in both the Philippines and the USA. Follow-up data were maintained as required by the Organ Procurement and Transplantation Network in the USA. RESULTS AND LIMITATIONS: The Filipino donor has normal blood pressure and renal function, and the Filipino recipient is doing well 3.5 yr after their donation and transplantation. CONCLUSIONS: While criticisms of GKE highlight concerns for possible exploitation of financially disadvantaged groups, these results demonstrate that these concerns did not come to fruition, and the outcome experienced by the GKE donor and recipient (and other US participants) was successful. PATIENT SUMMARY: The first Filipino Global Kidney Exchange (GKE) donor-recipient pair continues to be followed by both US and Filipino transplant centers. Both are in good health, support the GKE program, and advocate for its expansion.
Asunto(s)
Donación Directa de Tejido/tendencias , Trasplante de Riñón/economía , Donadores Vivos/estadística & datos numéricos , Pobreza/etnología , Obtención de Tejidos y Órganos/organización & administración , Receptores de Trasplantes/estadística & datos numéricos , Adulto , Anciano , Altruismo , Femenino , Estudios de Seguimiento , Histocompatibilidad/inmunología , Humanos , Trasplante de Riñón/ética , Trasplante de Riñón/métodos , Masculino , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud , Filipinas/epidemiología , Diálisis Renal/economía , Obtención de Tejidos y Órganos/normas , Estados Unidos/epidemiologíaRESUMEN
INTRODUCTION: In individuals with nonvalvular atrial fibrillation, anticoagulant therapy with warfarin reduces the rate of thromboembolic events but increases the risk of bleeding. Treatment decisions frequently are inconsistent with guidelines. A new web-based atrial fibrillation decision-support tool (AF-DST) provides patient-specific information on the risk-benefit tradeoff of anticoagulation. METHODS: The authors performed a pilot usability testing study of the AF-DST with 4 medical house officers and 4 attending physicians by simulating 9 outpatient clinical encounters involving tradeoffs between risks and benefits of anticoagulation. They recorded positive and negative critical incidents in the simulations and assessed satisfaction with use of the AF-DST by the Computer System Usability Questionnaire (CSUQ; score range on each item: 1 = strongly disagree to 7 = strongly agree). RESULTS: Users found the AF-DST to be helpful and had high CSUQ scores (mean item score, 6.3). Usability testing identified 6 positive and 14 negative critical incidents. Participants felt that the AF-DST guided them toward the correct decision. Nevertheless, they desired more information on the "black box" calculations and ignored alerts. Training level appeared to affect how the AF-DST was used, in particular, how users interacted with the AF-DST. CONCLUSIONS: Overall satisfaction with the AF-DST was high and the tool effectively communicated recommendations and uncertainty. Usability testing identified design issues and potential errors caused by decision-support tool use; these gaps should be addressed prior to clinical implementation.
RESUMEN
We report a chain of 10 kidney transplantations, initiated in July 2007 by a single altruistic donor (i.e., a donor without a designated recipient) and coordinated over a period of 8 months by two large paired-donation registries. These transplantations involved six transplantation centers in five states. In the case of five of the transplantations, the donors and their coregistered recipients underwent surgery simultaneously. In the other five cases, "bridge donors" continued the chain as many as 5 months after the coregistered recipients in their own pairs had received transplants. This report of a chain of paired kidney donations, in which the transplantations were not necessarily performed simultaneously, illustrates the potential of this strategy.
Asunto(s)
Trasplante de Riñón , Donadores Vivos , Obtención de Tejidos y Órganos/métodos , Sistema del Grupo Sanguíneo ABO/inmunología , Adulto , Altruismo , Femenino , Prueba de Histocompatibilidad , Humanos , Masculino , Persona de Mediana Edad , Obtención de Tejidos y Órganos/organización & administraciónRESUMEN
As home visitation programs go to scale, numerous challenges are faced in implementation and quality assurance. This article describes the origins and implementation of Every Child Succeeds, a multisite home visitation program in southwestern Ohio and Northern Kentucky. In order to optimize quality assurance and generate new learning for the field, a Web-based system (eECS) was designed to systematically collect and use data. Continuous quality assurance procedures derived from business and industry have been established. Findings from data collection have documented outcomes, and have identified clinical needs that potentially undermine the impact of home visitation. An augmented module approach has been used to address these needs, and a program to treat maternal depression is described as an example of this approach. Challenges encountered are also discussed.
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Maltrato a los Niños/prevención & control , Servicios de Salud del Niño/normas , Medicina Comunitaria/normas , Salud de la Familia , Visita Domiciliaria , Desarrollo de Programa , Garantía de la Calidad de Atención de Salud , Calidad de la Atención de Salud , Adolescente , Adulto , Niño , Preescolar , Conducta Cooperativa , Femenino , Humanos , Internet , Relaciones Interprofesionales , Kentucky , Ohio , Evaluación de Resultado en la Atención de Salud , Evaluación de Programas y Proyectos de SaludRESUMEN
By applying proven models in user-interface design and training, we deployed a Web-based data collection and reporting system that has been enthusiastically embraced by users with limited computer equipment and skills. Social workers and nurses now submit forms paperlessly as they visit thousands of new mothers across seven counties. The value of the underlying database has been enhanced by immediate validity checks, up-to-the-minute summary reports, and instantaneous access to all previous entries.
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Sistemas de Información en Atención Ambulatoria , Servicios de Atención de Salud a Domicilio/organización & administración , Interfaz Usuario-Computador , Preescolar , Humanos , Lactante , Recién Nacido , Ohio , Servicio SocialRESUMEN
The Ohio Solid Organ Transplantation Consortium (OSOTC) has a mission to ensure equitable access to transplant services to those most likely to benefit, regardless of personal resources. Patients are selected according to criteria established by the OSOTC, which are delineated in the Ohio Department of Health rule, and consistent with national criteria. The University of Cincinnati's Institute for Health Policy and Health Services Research (IHPHSR) has implemented a secure internet-based system to replace the OSOTC's existing fax-based procedures. This system meets both the patient evaluation and basic research needs of the OSOTC.
Asunto(s)
Trasplante de Corazón , Obtención de Tejidos y Órganos/organización & administración , Humanos , Internet , Ohio , Selección de Paciente , Sistema de Registros , Obtención de Tejidos y Órganos/normasRESUMEN
The Israel Penn International Transplant Tumor Registry is literally the world's premier repository of information on patients who have developed malignancies after organ transplants. The administrators of the Registry not only collect information but also provide consulting services based on the accumulated knowledge that the Registry contains. By creating a secure Web-based front end, we have made it possible for the Registry to keep pace with its burgeoning international caseload.