Self-management in liver transplantation.

BACKGROUND: Self-management is crucial for liver transplant (LT) recipients to maintain transplants and optimize health outcomes. However, previous literature has been primarily limited to examining medication adherence; there is a knowledge gap regarding self-management in the LT population. AIM: The aims of this study were to 1) comprehensively describe self-management behaviors and activities in LT recipients, 2) explore levels of overall self-management, and 3) explore the relationships of self-efficacy, cognition, and health information seeking behavior with self-management. METHODS: Adult LT recipients (n = 113) who had a functioning transplant for at least 6 months participated in this cross-sectional, descriptive study. Participants were asked to identify self-management behaviors and rate their performance of those behaviors, including symptom management and medication adherence. They also completed a cognitive assessment and questionnaires measuring self-efficacy and health information seeking behavior. Descriptive statistics, latent profile analysis, and probit model for path analysis were used for the data analysis. RESULTS: LT recipients acknowledged engaging in various self-management behaviors including symptom management, physical activity, maintenance of positive attitudes, and communication with healthcare providers. Three levels of self-management (i.e., low, medium, and high) were found; a high level of self-management was related to self-efficacy and health information seeking behavior. CONCLUSIONS: The findings indicate that self-management may be improved with interventions aimed at increasing self-efficacy and health information seeking behavior. Findings from this study will inform future interventions, to improve self-management and subsequent health outcomes in this population. Future longitudinal studies are necessary to confirm the causality of the identified relationships.

Self-Management in Liver Transplant Recipients: A Narrative Review.

INTRODUCTION: Although self-management is essential for liver transplant recipients, there is no review that has synthesized findings related to self-management in this population. OBJECTIVE: This narrative review aimed to synthesize the current findings and identify the gaps in knowledge about self-management in liver recipients. METHODS: A search of PubMed, CINAHL Plus, PsychINFO, ProQuest, and Web of Science was conducted using the following terms: [Self-care OR Self-management OR Health behavior] AND [Liver transplantation]. Peer-reviewed published research articles focusing on self-management of adult recipients were selected. A total of 23 articles were included for review. Two reviewers independently reviewed the full text of selected articles and extracted the data about definitions, measurements, and findings regarding self-management. RESULTS: Three areas of self-management were identified, including medication nonadherence (n = 11), alcohol recidivism (n = 11), and health maintenance (n = 5). Reported rates of medication nonadherence ranged from 8% to 66%. Medication nonadherence was related to recipients' demographic (eg, age or sex), transplant-related (eg, time since transplant), and pretransplant variables (eg, history of substance/alcohol abuse). Reported alcohol recidivism rates ranged from 3% to 95%. Age, pretransplant variables (eg, abstinent time before transplant), and personality disorder were identified to be related to alcohol recidivism after transplant. The health maintenance studies discussed behaviors such as smoking, clinic appointment attendance, or vaccination/health screening behaviors of recipients. DISCUSSION: Self-management studies in liver recipients have been narrowly focused on medication nonadherence and alcohol recidivism. To improve self-management in recipients, self-management beyond medication nonadherence and alcohol recidivism should be comprehensively examined.

What are patients saying about sex after a kidney or simultaneous kidney/pancreas transplant?

Context-Chronic illnesses such as kidney failure and diabetes and their treatments can affect people's identity, including their sexual identity. Little is known about patients' perspective on the effect of transplant on their sexual identity. Objective-To explore the sexual concerns of kidney and simultaneous pancreas/kidney transplant recipients. Design-Descriptive, qualitative. Setting-Major Midwestern university hospital. Patients-143 kidney and 70 pancreas/kidney transplant recipients; most were male (63.0%), married (64.7%), and white (83.7%), and the mean age was 49 years. Intervention-The qualitative data reported in this manuscript are derived from 2 larger quantitative studies of sexuality and quality of life in kidney and pancreas/kidney transplant recipients. The questionnaire in those studies included 2 open-ended questions that allowed participants to share their experiences as transplant recipients. Main Outcome Measure-Two faculty and 3 students did a conventional content analysis on patients' responses to the open-ended questions. Codes were extracted from the responses and then themes were created that best represented the codes. Results-Participants shared how sexual concerns affected their identity as sexual beings after transplant. Based on the responses to these open-ended questions, 4 themes were identified: sexual functioning, health care concerns, relationship with partner, and appearance changes. The study results indicate the need for improved education and provider-initiated dialogue related to sexuality after transplant.

Sexual concerns among kidney transplant recipients.

BACKGROUND: Little is known about the specific sexual concerns of kidney transplant (KTx) recipients. The primary objectives of this study were to: (i) describe the importance of sexuality to KTx recipients; (ii) investigate the sexual concerns of KTx recipients; and (iii) examine the relationship between sexual concerns and quality of life (QOL). A secondary objective was to examine potential sexual concern differences by gender, pre-transplant dialysis status, and donor type. METHODS: This study employed a cross-sectional, descriptive, correlational design. Sexual concerns were identified using the Sexual Concerns Questionnaire, which contains seven subscales. QOL was measured with the SF-8 and the QOL Uniscale. RESULTS: Nearly 73% of subjects rated sexuality as important. Subscales indicating highest area of sexual concerns were communication with healthcare providers about sexuality (Mean (M) = 2.70) and sexual pleasure concerns (M = 2.45). Higher concern ratings regarding health consequences of sexual activity, quality of sexual relationship, sexual pleasure, sexual functioning problems, and pessimistic beliefs about treatment were significantly, inversely related to QOL. Women had significantly higher scores on the Sexual Pleasure and Communication with Healthcare Providers subscales than men. CONCLUSIONS: This study reports the sexual concerns of KTx recipients' who are an average of four yr since surgery, and the relationship of these concerns to QOL.

Are Sexually Transmitted Infection/HIV Behavioral Interventions for Women of Color Culturally Grounded? A Review of the Literature.

Although behavioral interventions for women of color have been shown to be effective in reducing sexually transmitted infections (STIs), STI/HIV rates continue to increase. To alleviate sexual health disparities, it is necessary to understand the cultural behaviors of the target population to design culturally grounded interventions. The purposes of our review were to examine the current state of STI/HIV behavioral interventions for women of color, determine how culture has been incorporated into interventions, and identify gaps in the literature. We reviewed 17 articles targeting women of color between the ages of 13 and 65 years. Findings suggest the need for interventions that are culturally grounded, group based, and delivered face-to-face and in multiple sessions to reduce STI/HIV risk behaviors. Although many of the studies were effective, we found three major gaps: (a) the need to examine intervention sustainability, (b) limitations in the adaption of theoretical frameworks, and (c) clarity in how to infuse culture into interventions.

Noninvasive assessment of early kidney allograft dysfunction by blood oxygen level-dependent magnetic resonance imaging.

BACKGROUND: Blood oxygen level-dependent (BOLD) magnetic resonance imaging (MRI) is a noninvasive method to assess tissue oxygen bioavailability, using deoxyhemoglobin as an endogenous contrast agent. We hypothesized that BOLD-MRI could accurately discriminate different types of rejection early after kidney transplantation. METHODS: Twenty-three patients underwent imaging in the first four months posttransplant. Five had normal functioning transplants and 18 had biopsy-proven acute allograft dysfunction (acute tubular necrosis [ATN, n=5] and acute rejection [n=13] including borderline rejection: n=3; IA rejection: n=4; IIA rejection: n=6: C4d(+) rejection: n=9). RESULTS: Mean medullary R2* (MR2*) levels (a measure directly proportional to tissue deoxyhemoglobin levels) were significantly higher in normal functioning allografts (R2*=24.3/s+/-2.3) versus acute rejection (R2*=16.6/s+/-2.1) and ATN (R2*=20.9/s+/-1.8) (P<0.05). The lowest MR2* levels were observed in acute rejection episodes with vascular injury i.e. IIA and C4d (+). Similarly, the lowest medullary to cortical R2* ratios (MCR2*) were present in allografts with IIA (1.24+/-0.05) and C4d(+) rejection (1.26+/-0.06). ROC curve analyses suggested that MR2* and MCR2* values could accurately discriminate acute rejection in the early posttransplant period. CONCLUSIONS: BOLD-MRI demonstrated significant changes in medullary oxygen bioavailability in allografts with biopsy-proven ATN and acute rejection, suggesting that there may be a role for this noninvasive tool to evaluate kidney function early after transplantation.

Sexuality among women recipients of a pancreas and kidney transplant.

Significant improvements in health and quality of life generally follow organ transplantation; however, there is evidence that women who have received transplants experience difficulty with sexual function. The specific nature and extent of this difficulty has not been documented. The purpose of this study was to describe sexual functioning and sexual self-esteem among women recipients of a simultaneous pancreas and kidney transplant. Perceived effect of the transplant on sexuality was also explored. Participants completed a questionnaire that measured their sexual functioning (including sexual difficulties), sexual self-esteem, illnesses, medications, and perceived effect of the transplant on sexuality. Data analysis revealed that only 39% of the women would be classified as having normal sexual functioning. The majority reported either some difficulty with sexual function (34%) or sexual dysfunction (27%). About one third of the women reported that transplantation had only positive effects on their sexuality, whereas 28% reported negative effects, and 29% reported no effect.

Informational needs of liver transplant recipients during a two-year posttransplant period.

OBJECTIVES: To describe the informational needs of liver transplant (LTx) recipients, examine potential differences in informational needs by sociodemographic and clinical variables, and examine informational needs at various time points posttransplant. METHODS: A descriptive, cross-sectional design was used. Informational needs were assessed by the Informational Needs Questionnaire-liver, a new questionnaire developed to include LTx recipients' perspectives. To examine informational needs at different posttransplant time points, participants were classified into four groups (0-1, 2-4, 5-9, and 10-24 months). RESULTS: Participants (159) who were married, single, had higher education, or higher monthly incomes had significantly greater informational needs. Informational needs regarding disease and physical and emotional management remained high after transplant. Four subscales (medication, wound management, diet, and daily and social activities) indicated informational needs were different across time. Participants 2-4 months posttransplant had higher informational needs regarding wound management and daily and social activities. Participants 5-9 months posttransplant had the highest informational needs regarding medication and diet. DISCUSSION: Findings indicate informational needs vary among LTx recipients at different posttransplant time points. Marital status, education, and monthly income can influence informational needs. CONCLUSION: Healthcare providers should tailor information given to LTx recipients based on informational needs. Longitudinal studies are needed to confirm changing patterns of informational needs.

Depicting Changes in Multiple Symptoms Over Time.

Ridit analysis, an acronym for Relative to an Identified Distribution, is a method for assessing change in ordinal data and can be used to show how individual symptoms change or remain the same over time. The purposes of this article are to (a) describe how to use ridit analysis to assess change in a symptom measure using data from a longitudinal study, (b) give a step-by-step example of ridit analysis, (c) show the clinical relevance of applying ridit analysis, and (d) display results in an innovative graphic. Mean ridit effect sizes were calculated for the frequency and distress of 64 symptoms in lung transplant patients before and after transplant. Results were displayed in a bubble graph. Ridit analysis allowed us to maintain the specificity of individual symptoms and to show how each symptom changed or remained the same over time. The bubble graph provides an efficient way for clinicians to identify changes in symptom frequency and distress over time.

Development and Psychometric Testing of a Sexual Concerns Questionnaire for Kidney Transplant Recipients.

BACKGROUND AND PURPOSE: This study describes the development and psychometric testing of the Sexual Concerns Questionnaire (SCQ) in kidney transplant (KTx) recipients. METHODS: Construct validity was assessed using the Kroonenberg and Lewis exploratory/confirmatory procedure and testing hypothesized relationships with established questionnaires. Configural and weak invariance were examined across gender, dialysis history, relationship status, and transplant type. Reliability was assessed with Cronbach's alpha, composite reliability, and test-retest reliability. RESULTS: Factor analysis resulted in a 7-factor solution and suggests good model fit. Construct validity was also supported by the tests of hypothesized relationships. Configural and weak invariance were supported for all subgroups. Reliability of the SCQ was also supported. CONCLUSIONS: Findings indicate the SCQ is a valid and reliable measure of KTx recipients' sexual concerns.

Self-management priority setting and decision-making in adults with multimorbidity: a narrative review of literature.

OBJECTIVES: The purpose of this narrative review was to synthesize current research findings related to self-management, in order to better understand the processes of priority setting and decision-making among adults with multimorbidity. DESIGN: A narrative literature review was undertaken, synthesizing findings from published, peer-reviewed empirical studies that addressed priority setting and/or decision-making in self-management of multimorbidity. DATA SOURCES: A search of PubMed, PsychINFO, CINAHL and SocIndex databases was conducted from database inception through December 2013. References lists from selected empirical studies and systematic reviews were evaluated to identify any additional relevant articles. REVIEW METHODS: Full text of potentially eligible articles were reviewed and selected for inclusion if they described empirical studies that addressed priority setting or decision-making in self-management of multimorbidity among adults. Two independent reviewers read each selected article and extracted relevant data to an evidence table. Processes and factors of multimorbidity self-management were identified and sorted into categories of priority setting, decision-making, and facilitators/barriers. RESULTS: Thirteen articles were selected for inclusion; most were qualitative studies describing processes, facilitators, and barriers of multimorbidity self-management. The findings revealed that patients prioritize a dominant chronic illness and re-prioritize over time as conditions and treatments change; that multiple facilitators (e.g. support programs) and barriers (e.g. lack of financial resources) impact individuals' self-management priority setting and decision-making ability; as do individual beliefs, preferences, and attitudes (e.g., perceived personal control, preferences regarding treatment). CONCLUSIONS: Health care providers need to be cognizant that individuals with multimorbidity engage in day-to-day priority setting and decision-making among their multiple chronic illnesses and respective treatments. Researchers need to develop and test interventions that support day-to-day priority setting and decision-making and improve health outcomes for individuals with multimorbidity.

Factors affecting employment at initiation of dialysis.

BACKGROUND AND OBJECTIVES: Half the individuals who reach ESRD are working age (< 65 years old) and many are at risk for job loss. Factors that contribute to job retention among working-age patients with chronic kidney disease before ESRD are unknown. The purpose of the study is to understand factors associated with maintaining employment among working-age patients with advanced kidney failure. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: In this retrospective study we reviewed the United States Renal Data System database (1992 through 2003) and selected all patients (n = 102,104) who were working age and employed 6 months before dialysis initiation. Factors that were examined for an association with maintaining employment status included demographics, comorbid conditions, ESRD cause, insurance, predialysis erythropoietin use, and dialysis modality. RESULTS: Maintaining employment at the same level during the final 6 months before dialysis was more likely among (1) white men ages 30 to 49 years; (2) patients with either glomerulonephritis, cystic, or urologic causes of renal failure; (3) patients choosing peritoneal dialysis for their first treatment; (4) those with employer group or other health plans; and (5) erythropoietin usage before ESRD. Maintaining employment status was less likely among patients with congestive heart failure, cardiovascular disease, cancer, and other chronic illnesses. CONCLUSIONS: The rate of unemployment in working-age patients with chronic kidney disease and ESRD is high compared with that of the general population. Treating anemia with erythropoietin before kidney failure and educating patients about work-friendly home dialysis options might improve job retention.

Sexuality, an important component of the quality of life of the kidney transplant recipient.

People who receive a kidney transplant experience overall better quality of life (QOL) than those on dialysis. However, one area of QOL that does not seem to improve after transplant is sexuality. The purposes of this review were to evaluate the literature specific to sexuality after kidney and kidney/pancreas transplant, identify gaps in the literature, and suggest directions for future research. Sources for this review included studies published in nursing and medical journals as well as studies from the related fields of social work and psychology. This literature review revealed several factors that may affect posttransplant sexuality and sexual functioning including chronic illnesses, pretransplant dialysis, and medication side effects. In addition, numerous studies have shown that problems with sexual functioning are prevalent in the transplant population affecting up to 50% of kidney transplant recipients. These problems have a strong negative association with QOL and life satisfaction. Future research should focus on identifying the specific sexual concerns of kidney transplant recipients and on the development and testing of interventions to help alleviate these concerns.

BOLD-MRI assessment of intrarenal oxygenation and oxidative stress in patients with chronic kidney allograft dysfunction.

Blood oxygen level-dependent (BOLD) magnetic resonance imaging (MRI) uses deoxyhemoglobin as an endogenous contrast agent for the noninvasive assessment of tissue oxygen bioavailability. We hypothesized that intrarenal oxygenation was impaired in patients with chronic allograft nephropathy (CAN). Ten kidney-transplant recipients with CAN and nine healthy volunteers underwent BOLD-MRI. Medullary R2* (MR2*) and cortical R2* (CR2*) levels (measures directly proportional to tissue deoxyhemoglobin levels) were determined alongside urine and serum markers of oxidative stress (OS): hydrogen peroxide (H(2)O(2)), F(2)-isoprostanes, total nitric oxide (NO), heat shock protein 27 (HSP27), and total antioxidant property (TAOP). Mean MR2* and CR2* levels were significantly decreased in CAN (increased local oxyhemoglobin concentration) compared with healthy volunteers (20.7 +/- 1.6 vs. 23.1 +/- 1.8/s, P = 0.03 and 15.9 +/- 1.9 vs. 13.6 +/- 2.3/s, P = 0.05, respectively). There was a significant increase in serum and urine levels of H(2)O(2) and serum HSP27 levels in patients with CAN. Conversely, urine NO levels and TAOP were significantly increased in healthy volunteers. Multiple linear regression analyses showed a significant association between MR2* and CR2* levels and serum/urine biomarkers of OS. BOLD-MRI demonstrated significant changes in medullary and cortical oxygen bioavailability in allografts with CAN. These correlated with serum/urine biomarkers of OS, suggesting an association between intrarenal oxygenation and OS.

Life after transplantation: new transitions in quality of life and psychological distress.

Individuals with kidney failure often elect to undergo kidney transplantation because they believe that they will be more active and return a sense of normality to their lives with a functioning transplant. Therefore it is important to assess whether these objectives are being met. To do so, we can examine health-related quality of life (HRQOL) in transplant recipients. A number of tools have been used for this purpose, including general HRQOL instruments such as the 36-item short-form health survey (SF-36) and transplant-specific surveys such as the Kidney Transplant Questionnaire. In general, HRQOL assessments improve with transplantation in functional and physical domains. However, many factors actually influence HRQOL in a negative way, including comorbid conditions, kidney function per se, rejection episodes and hospitalizations, employment status, and adverse effects of medications. Perceived physical appearance, issues related to sexuality, stress, anxiety, and even guilt complicate the emotional and psychological landscape after transplantation. This constellation of factors may be predictive of posttransplant life events, such as resumption of employment. Posttransplant HRQOL may be exceedingly important in understanding the issues related to adherence with treatment regimens, especially in the pediatric and adolescent transplant populations. HRQOL is now established as an important issue after transplantation. Nonetheless, shortcomings still exist in our ability to address HRQOL after transplantation. In particular, more study of patient-centered interventions is needed. The use of standardized methodologies for patient assessment could improve our ability to identify if such patient-centered interventions actually succeed across populations, and help us further address the panoply of factors encompassed within posttransplant HRQOL.

ATR blockade reduces IFN-gamma production in lymphocytes in vivo and in vitro.

BACKGROUND: Type 1 angiotensin II (Ang II) receptor (AT(1)R) signaling induces proinflammatory responses. Recent studies suggest that T lymphocytes express AT(1)R; yet the effects of Ang II binding to AT(1)R on T cells are poorly understood. We examined the effect of AT(1)R blockade on release of the proinflammatory cytokine, interferon-gamma (IFN-gamma) by human lymphocytes in vivo and in vitro. METHODS: We used an AT(1)R blocker losartan in a randomized clinical trial in kidney transplant recipients over a 12-month period [AT(1)R blocker (N= 11) and control (N= 10)]. Peripheral blood lymphocytes, isolated from both cohorts, were analyzed by enzyme-linked immunosorbent spot assays (ELISPOT) analyses and real-time reverse transcription-polymerase chain reaction (RT-PCR) to enumerate IFN-gamma producing T cells and IFN-gamma mRNA levels. The effects of AT(1)R blockade in vitro were assessed using human alloreactive T cells and an IFN-gamma producing human cytotoxic T-lymphocyte line. Alloreactive T cells were treated with losartan or candesartan and enzyme-linked immunosorbant assay (ELISA) was used to measure IFN-gamma protein release. The cytotoxic T-lymphocyte line also was AT(1)R blocker-treated prior to determining IFN-gamma producing cells by intracellular cytokine staining. RESULTS: The AT(1)R blocker cohort had a significant decrease in IFN-gamma producing peripheral blood lymphocytes (P< or = 0.05 for each time point) and IFN-gamma mRNA levels (P= 0.01 vs. control patients). Losartan also decreased IFN-gamma production (P < 0.001) in purified alloreactive T cells in vitro as did candesartan. Moreover, Ang II amplified IFN-gamma generation (P < 0.05) in alloreactive T cells while AT(1)R blocker treatment inhibited Ang II's effect (P < 0.04). AT(1)R blocker treatment furthermore also inhibited IFN-gamma production in the cytotoxic T-lymphocyte line. CONCLUSION: AT(1)R blockers may have a clinically relevant immunomodulatory role by blocking IFN-gamma production in T cells.

Donor genomics influence graft events: the effect of donor polymorphisms on acute rejection and chronic allograft nephropathy.

BACKGROUND: Organs procured from deceased donors emanate from individuals with diverse genetic backgrounds. Donor organs, therefore, may vary in their response to injury and immune stimuli in a genetically determined manner. We assessed polymorphisms from 244 renal allograft donors to better understand the impact of donor polymorphisms on selected transplant outcomes. METHODS: Donor genomic DNA restriction fragment length polymorphisms were assayed for evidence of common cytokine [interleukin (IL)-2, IL-6, IL-10, tumor necrosis factor (TNF)-alpha, TGF-beta, interferon (IFN)-gamma] and chemokine (CCR2, CCR5) polymorphisms. Associations between donor polymorphisms and graft events were determined using chi-square, linear regression, and Kaplan-Meier analyses. RESULTS: Several genotypic polymorphisms demonstrated a modest association with acute rejection, including the transforming growth factor (TGF)-beta T/C codon 10 (P= 0.027) and the CCR5 G/A 59029 (P= 0.039) genes by chi-square analysis. Notably, the presence of the T allele in the IFN-gamma gene (+874) demonstrated a highly significant association with biopsy-proven chronic allograft nephropathy (P < 0.008). This association remained highly significant in a multiple linear regression model that incorporated biopsy-proven acute rejection as a covariate. CONCLUSION: These data suggest that many of the donor polymorphisms studied in this analysis may influence a recipient's immune response to a renal allograft. However, their greatest impact may be demonstrated in long-term outcomes.