RESUMO
INTRODUCTION: IgA nephropathy (IgAN) can cause end-stage kidney disease (ESKD). This study assesses the impact of induction and maintenance immunosuppression on IgAN recurrence, graft survival, and mortality in living and deceased donor kidney transplants (LDKT and DDKT). METHODS: Retrospective analysis of the UNOS database in adults with ESKD secondary to IgAN who received kidney transplants between January 2000 and June 30, 2022. Patients with thymoglobulin (ATG), alemtuzumab, or basiliximab/daclizumab induction with calcineurin inhibitor (CNI) and mycophenolate mofetil (MMF) with or without prednisone maintenance were analyzed. Multivariate logistic regression was performed to identify factors correlated with IgA recurrence. Multivariable Cox regression analyses were performed for clinically suspected risk factors. Kaplan Meir Analysis was utilized for overall graft survival. RESULTS: Compared to ATG with steroid maintenance, alemtuzumab with steroid increased the odds of IgAN recurrence in DDKTs (OR 1.90, p < .010, 95% CI [1.169-3.101]). Alemtuzumab with and without steroid increased the odds of recurrence by 52% (p = .036) and 56% (p = .005), respectively, in LDKTs. ATG without steroids was associated with less risk of IgAN recurrence (HR .665, p = .044, 95% CI [.447-.989]), graft failure (HR .758, p = .002, 95% CI [.633-.907]), and death (HR .619, p < .001, 95% CI [.490-.783]) in DDKTs. Recurrence was strongly associated with risks of graft failure in DDKTs and LDKTs and death in LDKTs. CONCLUSION: In patients with IgAN requiring a kidney transplant, Alemtuzumab induction correlates with increased IgAN recurrence. Relapse significantly affects graft survival and mortality. ATG without steroids is associated with the least graft loss and mortality.
Assuntos
Glomerulonefrite por IGA , Falência Renal Crônica , Transplante de Rim , Adulto , Humanos , Imunossupressores/uso terapêutico , Alemtuzumab/uso terapêutico , Glomerulonefrite por IGA/tratamento farmacológico , Glomerulonefrite por IGA/cirurgia , Estudos Retrospectivos , Transplante de Rim/efeitos adversos , Falência Renal Crônica/cirurgia , Falência Renal Crônica/etiologia , Esteroides , Sobrevivência de Enxerto , Rejeição de Enxerto/etiologiaRESUMO
BACKGROUND: We hypothesized that alemtuzumab use is safe in pediatric kidney transplant recipients (KTRs) with equivalent long-term outcomes compared to other induction agents. METHODS: Using pediatric kidney transplant recipient data in the UNOS database between January 1, 2000, and June 30, 2022, multivariate logistic regression, multivariable Cox regression, and survival analyses were utilized to estimate the likelihoods of 1st-year and all-time hospitalizations, acute rejection, CMV infection, delayed graft function (DGF), graft loss, and patient mortality among recipients of three common induction regimens (ATG, alemtuzumab, and basiliximab). RESULTS: There were no differences in acute rejection or graft failure among induction or maintenance regimens. Basiliximab was associated with lower odds of DGF in deceased donor recipients (OR 0.77 [0.60-0.99], p = .04). Mortality was increased in patients treated with steroid-containing maintenance (HR 1.3 [1.005-1.7] p = .045). Alemtuzumab induction correlated with less risk of CMV infection than ATG (OR 0.76 [0.59-0.99], p = .039). Steroid-containing maintenance conferred lower rate of PTLD compared to steroid-free maintenance (HR 0.59 [0.4-0.8] p = .001). Alemtuzumab was associated with less risk of hospitalization within 1 year (OR 0.79 [0.67-0.95] p = .012) and 5 years (HR 0.54 [0.46-0.65] p < .001) of transplantation. Steroid maintenance also decreased 5 years hospitalization risk (HR 0.78 [0.69-0.89] p < .001). CONCLUSIONS: Pediatric KTRs may be safely treated with alemtuzumab induction without increased risk of acute rejection, DGF, graft loss, or patient mortality. The decreased risk of CMV infections and lower hospitalization rates compared to other agents make alemtuzumab an attractive choice for induction in pediatric KTRs, especially in those who cannot tolerate ATG.
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Alemtuzumab , Basiliximab , Rejeição de Enxerto , Hospitalização , Imunossupressores , Transplante de Rim , Humanos , Alemtuzumab/uso terapêutico , Criança , Masculino , Hospitalização/estatística & dados numéricos , Feminino , Rejeição de Enxerto/prevenção & controle , Imunossupressores/uso terapêutico , Adolescente , Pré-Escolar , Basiliximab/uso terapêutico , Lactente , Sobrevivência de Enxerto , Soro Antilinfocitário/uso terapêutico , Resultado do Tratamento , Estudos Retrospectivos , Função Retardada do Enxerto/epidemiologia , Infecções por CitomegalovirusRESUMO
The objective of this study was to investigate factors influencing one's decision to become a live kidney donor under the framework of sociotechnical systems, by expanding the focus to include larger organizational influences and technological considerations. Semi-structured interviews were conducted with live kidney donors who donated through University of Louisville Health, Trager Transplant Center, a mid-scale transplant program, in the years 2017 through 2019. The interview transcripts were analyzed for barriers and facilitators to live kidney donation within a sociotechnical system. The most salient facilitators included: having an informative, caring, and available care team; the absence of any negative external pressure toward donating; donating to a family or friend; and the ability to take extra time off work for recovery. The most recurrent barriers included: short/medium-term (<1 year) negative health impacts because of donation; the need to make minor lifestyle changes (e.g., less alcohol consumption) after donation; and mental health deterioration stemming from the donation process. The sociotechnical systems framework promotes a balanced system comprised of social, technical, and environmental subsystems. Assessing the facilitators and barriers from the sociotechnical system perspective revealed the importance of and opportunities for developing strategies to promote integration of technical subsystem, such as social media apps and interactive AI platforms, with social and environmental subsystems to enable facilitators and reduce barriers effectively.
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Transplante de Rim , Doadores Vivos , Humanos , Doadores Vivos/psicologia , Feminino , Masculino , Transplante de Rim/psicologia , Pessoa de Meia-Idade , Adulto , Entrevistas como Assunto , Pesquisa Qualitativa , Tomada de Decisões , IdosoRESUMO
BACKGROUND: There is a lack of data on the impact of donor liver function tests (LFTs) on pancreas transplantation outcomes. Understanding their contribution could expand the donor pool. METHODS: Using the UNOS database, data from January 2010-2022 was retrospectively analyzed. Multivariable cox regressions were performed to evaluate the association between LFTs (AST, ALT and total bilirubin levels), graft failure and mortality up to three years post-transplant. RESULTS: 9138 pancreas transplants were completed. Multivariate analysis showed no association between donor AST values > 500 U/L and increased rates of graft failure (p = 0.826) or mortality (p = 0.836). Similar findings were noted for donor ALT values > 500 U/L (p = 0.522 and p = 0.997, respectively). There was no correlation with graft failure (p = 0.322) or mortality (p = 0.423) for total bilirubin levels >3 mg/dL. CONCLUSION: LFTs in the deceased pancreas donor did not increase risk of graft failure or mortality following pancreas transplantation. Elevated LFTs should not serve as absolute contraindications to transplant.
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Bilirrubina , Sobrevivência de Enxerto , Testes de Função Hepática , Transplante de Pâncreas , Humanos , Transplante de Pâncreas/efeitos adversos , Estudos Retrospectivos , Masculino , Feminino , Adulto , Bilirrubina/sangue , Pessoa de Meia-Idade , Fatores de Risco , Fatores de Tempo , Doadores de Tecidos , Bases de Dados Factuais , Resultado do Tratamento , Alanina Transaminase/sangue , Aspartato Aminotransferases/sangue , Biomarcadores/sangue , Seleção do Doador , Aloenxertos , Medição de Risco , Regulação para Cima , Fígado/enzimologia , Valor Preditivo dos TestesRESUMO
BACKGROUND: Coronavirus disease 2019 (COVID-19) is associated with a prothrombotic state; leading to multiple sequelae. We sought to detect whether thromboelastography (TEG) parameters would be able to detect thromboembolic events in patients hospitalized with COVID-19. METHODS: We performed a retrospective multicenter case-control study of the Collaborative Research to Understand the Sequelae of Harm in COVID (CRUSH COVID) registry of 8 tertiary care level hospitals in the United States (US). This registry contains adult patients with COVID-19 hospitalized between March 2020 and September 2020. RESULTS: A total of 277 hospitalized COVID-19 patients were analyzed to determine whether conventional coagulation TEG parameters were associated with venous thromboembolic (VTE) and thrombotic events during hospitalization. A clotting index (CI) >3 was present in 45.8% of the population, consistent with a hypercoagulable state. Eighty-three percent of the patients had clot lysis at 30 min (LY30) = 0, consistent with fibrinolysis shutdown, with a median of 0.1%. We did not find TEG parameters (LY30 area under the receiver operating characteristic [ROC] curve [AUC] = 0.55, 95% CI: 0.44-0.65, P value = .32; alpha angle [α] AUC = 0.58, 95% CI: 0.47-0.69, P value = .17; K time AUC = 0.58, 95% CI: 0.46-0.69, P value = .67; maximum amplitude (MA) AUC = 0.54, 95% CI: 0.44-0.64, P value = .47; reaction time [R time] AUC = 0.53, 95% CI: 0.42-0.65, P value = .70) to be a good discriminator for VTE. We also did not find TEG parameters (LY30 AUC = 0.51, 95% CI: 0.42-0.60, P value = .84; R time AUC = 0.57, 95%CI: 0.48-0.67, P value .07; α AUC = 0.59, 95%CI: 0.51-0.68, P value = .02; K time AUC = 0.62, 95% CI: 0.53-0.70, P value = .07; MA AUC = 0.65, 95% CI: 0.57-0.74, P value < .01) to be a good discriminator for thrombotic events. CONCLUSIONS: In this retrospective multicenter cohort study, TEG in COVID-19 hospitalized patients may indicate a hypercoagulable state, however, its use in detecting VTE or thrombotic events is limited in this population.
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COVID-19 , Trombofilia , Tromboembolia Venosa , Adulto , Humanos , Tromboelastografia , Estudos de Casos e Controles , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/etiologia , Estudos de Coortes , COVID-19/complicaçõesRESUMO
BACKGROUND: Liver transplantation has inherent disparities but data is scarce in liver transplant (LT) candidates with acute alcohol-associated hepatitis (AAH). We aimed to investigate demographic inequities and its impact on survival outcomes among AAH LT candidates. METHODS: A retrospective analysis using the United Network of Organ Sharing database was conducted between 2000 and 2021. 25 981 LT recipients with alcohol-associated liver cirrhosis and 662 recipients with AAH were included. Waitlisted candidates were also evaluated. RESULTS: In comparison with alcohol-associated liver cirrhosis, AAH LT recipients were more likely Asian or "other" race and younger. Hispanics demonstrated better graft and patient survival (p < 0.05) but were less likely to be waitlisted and transplanted for AAH than for liver cirrhosis. Women with AAH were more likely to be waitlisted and transplanted. Pre-existing diabetes and male sex were associated with higher graft failure (25% and 8% respectively). Increasing recipient age were 2% more likely to experience negative outcomes. Chronicity of liver disease did not impact graft (p = 0.137) or patient survival (p = 0.145). CONCLUSION: Our results revealed demographic factors have a significant impact on transplant listing, organ allocation and survival outcomes. Further investigations are imperative to minimize disparities in LT evaluation and provide equity in healthcare.
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Hepatite , Transplante de Fígado , Humanos , Masculino , Feminino , Estudos Retrospectivos , Cirrose Hepática , DemografiaRESUMO
INTRODUCTION: There are higher rates of depression and suicidal ideation among those with chronic diseases, including end-stage renal disease, diabetes mellitus and liver disease. Suicide is the tenth leading cause of death worldwide and is more prevalent among transplant recipients. Although transplantation has the potential to improve quality of life, many transplant recipients commit suicide each year. The extent to which sex, race, age, type of insurance coverage, time on waitlist, comorbidities, immunosuppressive regimen and graft loss contribute to suicide risk in this population remains understudied. METHODS: We queried UNOS data collected between 1990 and 2019 to determine what risk factors contribute to suicide in the transplant population. Suicide mortality rate was calculated by determining the fraction of organ recipients who died by suicide since 1990 and was expressed as deaths per 100 000. Two groups (suicide and all other cause mortality) were compared via univariate and multivariate statistical analysis. Time to graft loss was estimated using a Kaplan Meier Product Limit method. A propensity score analysis was performed to match patients who committed suicide to those who did not, allowing us to balance the relatively small sample of size of the suicide cohort with the larger all other cause mortality group to minimize the effect of confounding variables. We estimated years of organ life lost using the restricted mean. Statistical significance was defined by p < .05. RESULTS: The data included 135 432 transplant deaths in total; the majority were kidney recipients-82 305 (61%). We determined suicide rates of .28%, .31%, and .44% for kidney, liver and pancreas, respectively, with an overall rate of .3%. Across all three organs the most significant risk factor was male sex. Non-Hispanic whites were also at elevated risk (OR = 2.16, p < .003). In the liver and kidney transplant groups, the odds of committing suicide were reduced by 4% with advancing age. The odds of taking one's own life was inversely related to BMI in the kidney and pancreas groups. We observed a doubling of suicide rates from .3% in 2014 to .6% in 2018. There were no other statistically significant correlations. CONCLUSION: Suicide is more prevalent among transplant recipients than in the general population. White males in particular are most at risk. The highest rate of suicide was in pancreas recipients. Advancing age and increasing BMI conferred some protective effect. There were no significant associations between suicide incidence and glucocorticoid use, type of insurance coverage, time on waitlist or graft loss. The phenomenon has become more prevalent in recent years.
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Sobrevivência de Enxerto , Suicídio , Humanos , Doadores Vivos , Masculino , Qualidade de Vida , Sistema de Registros , Fatores de Risco , TransplantadosRESUMO
Higher body mass index (BMI) of deceased-donors is associated with poorer outcomes in transplant recipients. The effect of low donor BMI on recipient graft function is not clear. Scientific Registry of Transplant Recipients data on recipients of deceased-donor kidneys from 2000 to 2019 were categorized by donor BMI (donor BMI < 18, 18-27, and >27). Primary outcome was death-censored graft survival. The impact of multiple recipient and donor variables, including low donor BMI and the difference between donor and recipient BMI, was evaluated using a multivariate Cox proportional-hazards model. Low BMI donors (LBD) were more likely to be younger, female, and white (all P < .05). LBD were less likely to be Hispanic, diabetic, or have hypertension (all P < .001). LBD recipients were more likely to be younger and female (both P < .001). Low donor BMI was not significantly associated with recipient graft survival. Donor-recipient BMI difference did not correlate with an increased risk of graft failure. Similar results were obtained when donors were classified using body surface area (BSA). Small donor size in terms of BMI or BSA or a large discrepancy between donor and recipient size should not necessarily preclude transplantation of an otherwise acceptable kidney.
Assuntos
Índice de Massa Corporal , Transplante de Rim , Doadores de Tecidos , Feminino , Sobrevivência de Enxerto , Humanos , Rim , Masculino , Transplantados , Resultado do TratamentoRESUMO
The average age of renal transplant recipients in the United States has increased over the past decade. The implications, however, have not been fully investigated. We explored predictors of success and demographic variables related to outcomes in elderly live donor transplantation. Retrospective analysis was performed using the UNOS database between 2001 and 2016. Donor characteristics and the graft failure rate of recipients above and below 70 years of age were compared across four eras: 2001-2004, 2005-2008, 2009-2012, and 2013-2016. There was a steady increase in average donor age from the first era to the fourth era (40-44) which was more evident among the septuagenarian patients (43-50) (P < .001). The 2-year graft survival rate improved from 92% in the first era to 96% in the fourth era (P < .001), and this was also more prominent in the >70 population (87%-93%) (P < .001). The >70 recipients were more likely to be non-Hispanic white (80.1% vs 65.1%, P < .001) and male (70.1% vs 61.0% P < .001), respectively. The donors were more likely to be non-Hispanic white and female in the >70 population. Live donation in the elderly is justified based on graft survival and patient survival. However, racial and gender differences exist in septuagenarian recipients and their donors.
Assuntos
Transplante de Rim , Doadores Vivos , Idoso , Feminino , Sobrevivência de Enxerto , Humanos , Masculino , Sistema de Registros , Estudos Retrospectivos , Doadores de Tecidos , Estados Unidos/epidemiologiaRESUMO
INTRODUCTION: Procurement practices across organ procurement organizations (OPOs) for donation after cardiac death (DCD) transplants have not been evaluated. METHODS: A national telephone survey of all 58 OPOs inquiring about their procurement practices of DCD organs was conducted. Policies concerning maximum donor body mass index (BMI), location of care withdrawal, pre-mortem heparin administration, vasodilator use, wait times after declaration of death before incisions, inclinations between rapid laparotomy and pre-mortem cannulation, and maximum time before aborting DCD procurement were queried. RESULTS: The survey revealed substantial differences across OPOs. Donor BMI restriction was considered by 36 of 58 OPOs, and 23 sites preferred OR for donor withdrawal of care. Pre-mortem heparin was utilized by 53 OPOs. Only 2 recommended vasodilators. Minimum wait time of 5-minutes was implemented by 41 OPOs. Rapid laparotomy was preferred by 57 organizations. 28 OPOs had a 90-minute limit before aborting DCD procurement. CONCLUSION: There are substantial variations across OPO protocols for procuring DCD organs. Current practices do not conform to ASTS guidelines for DCD procurement. Further investigations are needed to quantify the impact of OPO policies on transplant outcomes.
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Obtenção de Tecidos e Órgãos , Morte , Humanos , Políticas , Padrões de Referência , Doadores de TecidosRESUMO
BACKGROUND: Share 35 prioritizes offers of deceased donor livers to regional candidates with Model for End-Stage Liver Disease (MELD) ≥35 over local candidates with lower MELD scores. Analysis of Share35 has shown that overall 1- or 2-year post-transplant (LTx) outcomes have been unchanged while waitlist mortality has been reduced. However, these studies exclude retransplant (reLTx) recipients. This study aims to investigate the outcomes of liver retransplants in evaluating the impact of the Share35 policy. METHODS: A retrospective analysis of data from the United Network for Organ Sharing database over the period June 2011-June 2015 was performed. RESULTS: A total of 19,748 LTx and 312 reLTx recipients were identified. Of the LTx recipients, 9626 (48.7%) underwent transplant pre-Share 35 and 10,122 (51.3%) post-Share 35. 123 (39.4%) reLTx recipients underwent retransplantation pre-Share 35 and 189 (60.6%) post-Share 35. ReLTx recipients experienced improved 2-year graft survival post-Share 35 compared to pre-Share 35 (67% vs. 21.1%). Patient survival also improved at 2-years for reLTx recipients post-Share 35 compared to pre-Share 35 (69.2% vs. 33.1%). Transplant post-Share 35 was protective for both 2-year graft (HR = 0.669, CI = 0.454-0.985, p = 0.04) and patient (HR = 0.659, CI = 0.44-0.987, p = 0.003) survival. CONCLUSION: Share35 is associated with improved outcomes after retransplantation.
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Técnicas de Apoio para a Decisão , Seleção do Doador , Doença Hepática Terminal/cirurgia , Transplante de Fígado/métodos , Reoperação/métodos , Doadores de Tecidos/provisão & distribuição , Listas de Espera , Adulto , Idoso , Tomada de Decisão Clínica , Bases de Dados Factuais , Doença Hepática Terminal/diagnóstico , Doença Hepática Terminal/mortalidade , Feminino , Sobrevivência de Enxerto , Humanos , Transplante de Fígado/efeitos adversos , Transplante de Fígado/mortalidade , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Reoperação/efeitos adversos , Reoperação/mortalidade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do Tratamento , Listas de Espera/mortalidadeRESUMO
Identification of 'cut-points' or thresholds of climate factors would play a crucial role in alerting risks of climate change and providing guidance to policymakers. This study investigated a 'Climate Threshold' for emergency hospital admissions of chronic lower respiratory diseases by using a distributed lag non-linear model (DLNM). We analysed a unique longitudinal dataset (10 years, 2000-2009) on emergency hospital admissions, climate, and pollution factors for the Greater London. Our study extends existing work on this topic by considering non-linearity, lag effects between climate factors and disease exposure within the DLNM model considering B-spline as smoothing technique. The final model also considered natural cubic splines of time since exposure and 'day of the week' as confounding factors. The results of DLNM indicated a significant improvement in model fitting compared to a typical GLM model. The final model identified the thresholds of several climate factors including: high temperature (≥27°C), low relative humidity (≤ 40%), high Pm10 level (≥70-µg/m3), low wind speed (≤ 2 knots) and high rainfall (≥30mm). Beyond the threshold values, a significantly higher number of emergency admissions due to lower respiratory problems would be expected within the following 2-3 days after the climate shift in the Greater London. The approach will be useful to initiate 'region and disease specific' climate mitigation plans. It will help identify spatial hot spots and the most sensitive areas and population due to climate change, and will eventually lead towards a diversified health warning system tailored to specific climate zones and populations.
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Hospitalização/estatística & dados numéricos , Modelos Teóricos , Doenças Respiratórias/epidemiologia , Poluição do Ar/efeitos adversos , Clima , Serviço Hospitalar de Emergência/estatística & dados numéricos , Humanos , Umidade , Londres/epidemiologia , Estudos Longitudinais , Dinâmica não Linear , Material Particulado/efeitos adversos , Doenças Respiratórias/etiologia , Tempo (Meteorologia) , VentoRESUMO
How does government spending on environmental protection benefit people's health? The current paper analyzed 2010 and 2018 data from the China Family Panel Studies (CFPS) database to measure the impact of province-level environmental regulations on the health of local population. The study also applied the Alkire Foster method to develop the multidimensional health poverty (MHP) score, a new index intended to measure the health status of individuals in a holistic manner. Our results indicated that more fiscal spending on environmental regulation could improve health of the local population, especially among low-income population living in the rural areas. Further, the size of health benefit differs by the type of environmental regulation. More specifically, regulations focusing on preventing environmental pollution can achieve more sizable health benefits than remedial ones. Finally, fine inhalable particle (PM2.5) has the largest mediating effect on the relationship between environmental regulation and public health. These results provide several policy implications, which highlight the importance of: scaling up fiscal environmental expenditure and optimizing the structure of environmental expenditure with more emphasis on rural areas where more low-income population are located; shifting from ex-post accountability to ex-ante prevention; and strengthening regional cooperation in environmental protection among local governments, and establishing a cross-regional coordination mechanism.
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Unintentional injury death (UID) is a leading cause of mortality worldwide, and individuals with chronic diseases are at higher risk. Though organ transplant can improve the lives of those with chronic disease, these individuals remain in suboptimal physical and mental health after surgery that predisposes them to UID. To quantify the scale of UID among solid organ transplant recipients, we performed a retrospective analysis using United Network of Organ Sharing data from adults who underwent kidney, liver or pancreas transplant between 2000-2021. Our study aimed to identify risk factors for UID in this cohort by comparing basic patient, donor, and transplant characteristics of the groups (UID or all other cause death). The largest proportion of UID was seen in the kidney group (.8%), followed by liver (.7%) and then pancreas (.3%). Male sex was the most significant risk factor among kidney and liver recipients. Whites had a higher risk for UID relative to their non-White counterparts in the kidney and liver groups. In both groups, advancing age conferred a protective effect, whereas higher functional status was a risk factor. Our findings shed new light on a significant source of mortality within the transplant population.
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Transplante de Órgãos , Adulto , Humanos , Masculino , Estudos Retrospectivos , Transplante de Órgãos/efeitos adversos , Fatores de Risco , RimRESUMO
This study aimed to investigate both chronic health conditions and the utilization of patient portals, focusing particularly on caregivers responsible for individuals with Alzheimer's disease and related dementias (ADRD). Data from the Health Information National Trends Survey 2018-2020 were analyzed, involving a sample of 304 family and unpaid caregivers of individuals with ADRD. Among caregivers of individuals with ADRD, 77.6% had at least one chronic disease. A significant proportion (46.6%) of ADRD caregivers had never accessed their patient portals. The limited utilization of patient portals among caregivers responsible for individuals with ADRD, particularly those with lower education, advanced age, and few chronic conditions, becomes apparent due to challenges associated with digital literacy and discomfort with computers. Recognizing the crucial role caregivers play for individuals with ADRD and their health risks, there's a need for tailored training to enhance their health management skills and caregiving capabilities.
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Doença de Alzheimer , Portais do Paciente , Humanos , Cuidadores , Doença CrônicaRESUMO
OBJECTIVES: Urologists represent functional alternatives for transplant surgeons, but their involvement is minimal. Evaluating urologists' interests in transplant and identifying associated factors may help to determine whether recruitment of more urological providers is a viable strategy to address transplant surgeon shortages in the United States. MATERIALS AND METHODS: We emailed a 10-question survey to individuals pursuing urology in the United States and collected demographic data, education and training backgrounds, and preferences for proposed integrated residency programs and abbreviated transplant fellowships. We stratified respondents based on transplant interest (yes/no); we made comparisons by using t-tests for continuous variables and Fisher exact tests for categorical variables. We used multivariable logistic regression to identify factors associated with interest in transplant surgery. RESULTS: Of 104 respondents, 98 were included in the final analysis, with 47% indicating a current or prior interest in transplantation. Male respondents were 3.7 times more likely than female respondents to be interested (odds ratio = 4.675; 95% CI, 1.411-15.495; P = .012). Participants aged <30 years were 93% less likely than older participants to be interested in transplantation (odds ratio = 0.071; 95% CI, 0.006-0.779; P = .03). International medical graduates reported higher enthusiasm for transplantation compared with US-trained counterparts (89% vs 42%), with a trend toward significance (P = .06). Nearly all (93%, 43/46) who expressed interest endorsed having an integrated training pathway. Only 70% (32/46) supported an abbreviated fellowship (<24 mo). Lifestyle concerns and insufficient exposure during residency were the most frequently cited reasons for lack of interest. CONCLUSIONS: Compared with male and older urology trainees, female and younger urology trainees were less inclined to pursue transplant surgery. Nonetheless, urologists represent an untapped pool of transplant surgeons. Proposing an integrated training program for urologists and increasing exposure to transplantation during urology residency represent potential strategies to decrease transplant surgeon shortages.
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Atitude do Pessoal de Saúde , Escolha da Profissão , Cirurgiões , Urologistas , Humanos , Estudos Transversais , Masculino , Feminino , Urologistas/provisão & distribuição , Urologistas/educação , Adulto , Cirurgiões/educação , Cirurgiões/provisão & distribuição , Estados Unidos , Pessoa de Meia-Idade , Papel do Médico , Transplante de Órgãos , Urologia/educação , Inquéritos e Questionários , Educação de Pós-Graduação em Medicina , Conhecimentos, Atitudes e Prática em Saúde , Procedimentos Cirúrgicos Urológicos/educação , Bolsas de Estudo , Internato e ResidênciaRESUMO
OBJECTIVES: The demographic disparities among surgeons in academic leadership positions is well documented. We aimed to characterize the present demographic details of abdominal transplant surgeons who have achieved academic and clinical leadership positions. MATERIALS AND METHODS: We reviewed the 2022-2023 American Society of Transplant Surgeons membership registry to identify 1007 active abdominal transplant surgeons. Demographic details (academic and clinical titles) were collected and analyzed using the chi-square test, the Fisher exact test, and t tests. Multinomial logistic regressions were conducted. RESULTS: Female surgeons (P < .001) and surgeons from racial-ethnic minorities (P = .027) were more likely to be assistants or associates rather than full professors. White male surgeons were more likely to be full professors than were White female (P < .001), Asian female (P = .008), and Asian male surgeons (P = .005). There were no Black female surgeons who were full professors. The frequency of full professorship increased with surgeon age (P < .001). Male surgeons were more likely to hold no academic titles (P < .001). Female surgeons were less likely to be chief of transplant(P = .025), chief of livertransplant (P = .001), chief of pancreas transplant (P = .037), or chair of surgery (P = .087, significance at 10%). Chief of kidney transplant was the most common clinical position held by a surgeon from a racial or ethnic minority group. Female surgeons were more likely to hold no clinical titles (P = .001). CONCLUSIONS: The underrepresentation of women and people from racial and ethnic minority groups in academic and clinical leadership positions in the field of abdominal transplant surgery remains evident. White male physicians are more likely to obtain full professorship, and they comprise most of the clinical leadership positions overall. A continued push for representative leadership is needed.
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Minorias Étnicas e Raciais , Liderança , Transplante de Órgãos , Médicas , Cirurgiões , Humanos , Feminino , Masculino , Médicas/tendências , Cirurgiões/tendências , Transplante de Órgãos/tendências , Minorias Étnicas e Raciais/estatística & dados numéricos , Diversidade Cultural , Fatores Raciais , Docentes de Medicina/estatística & dados numéricos , Adulto , Mobilidade Ocupacional , Estados Unidos , Pessoa de Meia-Idade , Fatores Sexuais , Sistema de Registros , Grupos Minoritários/estatística & dados numéricosRESUMO
Introduction: Transplantation is a field with unique medical and administrative challenges that involve an equally diverse array of stakeholders. Expectantly, the litigation stemming from this field should be similarly nuanced. There is a paucity of comprehensive reviews characterizing this medicolegal landscape. Design: The Caselaw Access Project Database was used to collect official court briefs of 2053 lawsuits related to kidney, liver, heart, lung, and pancreas transplantation. A thematic analysis was undertaken to characterize grounds for litigation, defendant type, and outcomes. Cases were grouped into policy, discrimination, poor or unsuccessful outcome, or other categories. Results: One hundred sixty-four court cases were included for analysis. Cases involving disputes over policy coverage were the most common across all organ types (N = 55, 33.5%). This was followed by poor outcomes (N = 51, 31.1%), allegations of discrimination against prison systems and employers (N = 37, 22.6%) and other (N = 21, 12.8%). Defendants involved in discrimination trials won with the greatest frequency (N = 29, 90.62%). Defendants implicated in policy suits won 65.3% (N = 32), poor outcomes 62.2% (N = 28), and other 70% (N = 14). Of the 51 cases involving poor outcomes, plaintiffs indicated lack of informed consent in 23 (45.1%). Conclusion: Reconsidering the informed consent process may be a viable means of mitigating future legal action. Most discrimination suits favoring defendants suggested previous concerns of structural injustices in transplantation may not be founded. The prevalence of policy-related cases could be an indication of financial burden on patients. Future work and advocacy will need to substantiate these concerns and address change where legal recourse falls short.
Assuntos
Imperícia , Transplante de Órgãos , Humanos , Transplante de Órgãos/legislação & jurisprudência , Imperícia/legislação & jurisprudência , Imperícia/estatística & dados numéricos , Estados Unidos , Preconceito , Política de Saúde/legislação & jurisprudênciaRESUMO
This study analyzed data from the National COVID Cohort Collaborative (N3C) database to investigate whether high-density lipoprotein (HDL) and its major protein component, apolipoprotein A1 (apoA1), are associated with severe COVID-19 sequelae, specifically acute kidney injury (AKI) and severe COVID-19 disease as defined by the infection resulting in hospitalization, extracorporeal membrane oxygenation (ECMO), invasive ventilation, or death. Our study included a total of 1,415,302 subjects with HDL values and 3589 subjects with apoA1 values. Higher levels of both HDL and apoA1 were associated with a lower incidence of infection as well as a lower incidence of severe disease. Higher HDL levels were also associated with a lower incidence of developing AKI. Most comorbidities were negatively correlated with SARS-CoV-2 infection, presumably due to the behavioral changes that occurred as a result of the precautions taken by individuals with underlying comorbidities. The presence of comorbidities, however, was associated with developing severe COVID-19 disease and AKI. African American and Hispanic populations experienced worse outcomes, including a higher incidence of infection and the development of severe disease, as well as AKI. Smoking and being male were associated with a lower incidence of infection, while they were risk factors for the development of severe disease and AKI. The results on cholesterol and diabetes drugs warrant further research, given that the database included multiple drugs in each category impeding for analysis of specific medications. Despite the current limitations in the N3C data, this study is the first to investigate the roles of HDL and apoA1 on the outcomes of COVID-19 using the US population data.