Predictive value of the Charlson comorbidity index in kidney transplantation.

BACKGROUND: Nonimmunologic factors have been recently implicated in worse outcomes after kidney transplantation, producing a need to predict the operative risk among kidney recipients. We assessed the predictive value of the Charlson comorbidity index (CCI) among kidney transplant recipients. METHODS: A retrospective study of 223 first deceased-donor kidney transplantations performed from 2000 to 2007 evaluated the role of comorbidities. RESULTS: About 50% of recipients displayed >1 comorbid condition before transplantation; the most frequently reported was diabetes mellitus. Increasing CCI scores significantly affected graft and patient survivals. Crude analysis showed a significant association between CCI >1 and risk of death (hazard ratio [HR], 3.87; 95% confidence interval [CI], 1.06-14.06; P = .04). After adjustment for several covariates, high CCI values remained significantly predictive of posttransplantation outcomes with a HR for death of (12.53; 95% CI, 1.9-82.68; P = .009). CONCLUSIONS: Our predictive model showed a strong association of CCI and patient survival even after adjustment for several clinical covariates. CCI may be used to evaluate patients referred for kidney transplantation who display a significant burden of comorbid conditions that increase the risk of premature death or graft loss.

The role of obesity in kidney transplantation outcome.

BACKGROUND: The number of obese kidney transplant candidates has been growing. However, there are conflicting results regarding to the effect of obesity on kidney transplantation outcome. The aim of this study was to investigate the association between the body mass index (BMI) and graft survival by using continuous versus categoric BMI values as an independent risk factor in renal transplantation. METHODS: We retrospectively reviewed 376 kidney transplant recipients to evaluate graft and patient survivals between normal-weight, overweight, and obese patients at the time of transplantation, considering BMI as a categoric variable. RESULTS: Obese patients were more likely to be male and older than normal-weight recipients (P = .021; P = .002; respectively). Graft loss was significantly higher among obese compared with nonobese recipients. Obese patients displayed significantly lower survival compared with nonobese subjects at 1 year (76.9% vs 35.3%; P = .024) and 3 years (46.2% vs 11.8%; P = .035). CONCLUSIONS: Obesity may represent an independent risk factor for graft loss and patient death. Careful patient selection with pretransplantation weight reduction is mandatory to reduce the rate of early posttransplantation complications and to improve long-term outcomes.

Correlational study between psychic symptoms and quality of life among hemodialysis patients older than 55 years of age.

BACKGROUND: The loss of renal function and urination with dialysis can produce a strong emotional crisis in a patient. This study explored the correlation between psychic symptoms and quality of life among hemodialysis patients who were older than 55 years of age in relation to demographic characteristics of age, time on dialysis, and education. PATIENTS AND METHODS: Twenty patients undergoing hemodialysis were included in the study. The psychic symptoms were studied using the Symptom Checklist-90. Revised (SCL-90 R) and the quality of life was studied using the Complete Form Health Survey (SF 36). RESULTS: The high correlation between psychological sizes investigated through the SCL-90 R test and those for the SF-36 test confirmed the close relationship between physical disorders and mental suffering, and reduced vitality, and lack of socialization. CONCLUSION: The psychiatrist and psychologist may help hemodialysis patients to improve their quality of life by providing new coping strategies for each of the family, occupational, and social network.

Delayed graft function and long-term outcome in kidney transplantation.

BACKGROUND: There are still many controversies about the impact of delayed graft function (DGF) on kidney transplantation outcome. The aims of this study were to define factors associated with DGF and to ascertain the relative impact of DGF on kidney transplantation outcome, both in the early postoperative period and in long-term follow-up. PATIENTS AND METHODS: Four hundred kidney transplant recipients were reviewed to assess the clinical impact of DGF on long-term outcome. RESULTS: The overall prevalence of DGF was 24.3%. DGF was significantly associated with increasing recipient and donor age, duration of dialysis, and cold ischemia time. Patients with DGF displayed a significantly worse graft (P = .005) and patient (P < .001) survival compared with recipients with immediate function. CONCLUSION: DGF is a frequent complication of renal transplantation and may be associated with a reduced graft and even patient survival. Strategies to prevent graft injury and, more specifically, DGF may be an important clue to provide a better long-term outcome in kidney transplantation.

Clerodane diterpenes from Tinospora rumphii.

Two new diterpenes (1 and 2) were obtained from the leaves of Tinospora rumphii, along with the known compounds tinotufolin D and vitexilactone. The structures of compounds 1 and 2 were established on the basis of spectroscopic studies.

Character witness. Walking the talk on euthanasia.

Our response to the euthanasia movement brings us to the depths of moral character and spirituality. Character bears witness to the true significance of our Catholic convictions about the dignity of persons, the value of life, our dependence on God, and our interdependence on one another. To be credible players in public debates on euthanasia and assisted suicide, we have to bear convincing witness, personally and corporately, to the ways we care first for ourselves and for those who are not as fortunate as we--the sick, the elderly, the indigent, and the dying. Who we will be in the face of death will have a lot to do with what we have come to believe about life, with the values we have upheld, with the attitudes we have taken, and with the habits of thought and behavior we have formed. So we need not be victims of what dying has in store for us. Rather, we can engage our dying by developing those habits of the heart which will make a difference in the way we adapt to unwanted circumstances and endure what we cannot change. We cannot develop strength of character if we are not nurtured by a community of character. In addition to personal character, we also need to be a community that gives witness to those fundamental religious and moral convictions which shape our living and dying in ways that would make euthanasia unthinkable.

Moral principles shaping public policy on euthanasia.

People's fear of enduring a prolonged, costly dying while attached to life-sustaining machines has prompted support for the legalization of active euthanasia. Four major principles--sanctity of life, prohibition against killing, autonomy, and the common good--have a bearing on the debate.

The virtuous response to euthanasia. Caring must become the alternative to curing.

To show what makes euthanasia an affront to Catholics' most basic convictions, Catholics must be a virtuous community of interdependence, care, and hospitality. The Catholic community's challenge in opposing euthanasia is to help convert society from an aggregate of individuals pursuing their self-interests to an interdependent covenantal community. The Catholic healthcare community may contribute to the bonding that can make living interdependently liberating and life giving by being a catalyst for collaboration between the subcommunities within the Church--hospitals, schools, parishes, and religious organizations. To oppose euthanasia, caring must become the alternative to curing. Caring accepts decline and death as part of being human. A caring Catholic community can provide educational services to the wider community, focusing on managing health and assuming responsibility for treatment. In a community of hospitality the dying should be able to live as free from pain and as much in control as possible. Everyone who has contact with the sick, the elderly, and the dying has the moral responsibility to communicate that they are worthy of respect and are not being isolated or abandoned. Hospitality also must be directed to care givers. The lack of support for those who spend endless hours caring for the terminally ill has been a crucial factor in cases of euthanasia.

Quality of life: a focus on the patient's total good.

The quality-of-life factor used in making difficult decisions about life-sustaining treatment should refer to the patient's definition of meaningful survival. The significance of this is founded on theological convictions that respect life's value and promote its meaning according to the ability to actualize life's potential, especially through love. The appropriateness of quality-of-life criteria is entailed in the principle of beneficence: doing good for the patient. Beyond medical good, this must include each aspect of the patient's total good--autonomy, preferences, and ultimate (spiritual) good. The proportionate-disproportionate distinction exemplifies this by weighing treatment effects against patient benefits. The difficulty in applying the quality-of-life factor primarily involves who determines the criteria, as answered by one of three approaches: The "gold standard" gives priority to informed patients capable of deciding for themselves. The "silver standard" is the proxy judgment substituting for patients' previously communicated wishes. The "bronze standard" is the judgment made in patients' best interests when no wishes have been expressed. Healthcare delivery can address quality-of-life considerations using five guidelines: 1. Respect the wishes of informed patients capable of decision making. 2. Treat incompetent patients as similar patients have chosen to be treated. 3. Act to restore patients' capacity for meaningful relationships. 4. Determine if treatment yields a reasonable balance between treatment effects and patient benefits. 5. Refer doubtful treatment decisions to an institutional ethics committee.

Euthanasia: a Catholic perspective.

According to the Roman Catholic perspective, we are not obliged to ward off death at all costs, but we should not deliberately intervene to bring death about. The "sanctity of life" principle, which rests on the human person's unique relationship with God, is the basis of the Church's honoring of human life as a basic value. Under this principle, direct intervention to end the life of a patient in a terminal condition would not be condoned. This negative position also follows from the religious principle of divine sovereignty--the idea that God alone is Lord over life and death, and the end of human life is not subject to a person's free judgment. Catholic moral tradition distinguishes between actions, on the one hand, or omissions that constitute intervention to put the patient to death and, on the other hand, the withholding of useless treatment that could not significantly reverse or prolong the progressive deterioration of life. The distinction rests on the difference between ordinary and extraordinary means. Also to be considered is the intention--the physician's goals versus the foreseeable yet unintended results. Thus death may not be directly sought, but it may be tolerated as an inevitable side effect of one's goal (such as the relief of suffering). These moral principles need to be rooted in the specific ways a moral community cares for its sick and dying. The religious convictions of grace and covenant and corresponding virtues of gratitude and fidelity enable the community to uphold its convictions about euthanasia.