Care Of Renal Transplant Recipients Research Articles

Comprehensive Review of Urinary Tract Infections in Renal Transplant Recipients: Clinical Insights and Management Strategies.

Urinary tract infections (UTIs) pose a significant challenge in the care of renal transplant recipients. This comprehensive review explores this population's multifaceted landscape of UTIs, emphasizing the importance of early diagnosis and tailored management strategies. Renal transplant recipients face an elevated risk of UTIs due to immunosuppression, altered urinary tract anatomy, and complex comorbidities. Complications of UTIs can lead to graft dysfunction and systemic illness, underscoring the need for effective management. The emergence of multidrug-resistant uropathogens adds complexity to treatment, highlighting the importance of targeted antibiotic therapy. Antibiotics are the most commonly prescribed drugs for UTIs, with nitrofurantoin, fosfomycin, amoxicillin, and amoxicillin-clavulanate potassium being some of the commonly used antibiotics. However, the emergence of multidrug-resistant uropathogens has led to the exploration of alternative treatments, such as bacteriophage therapy, as a potential alternative against multidrug-resistant uropathogenic bacteria. Analgesics such as phenazopyridine can be prescribed to relieve discomfort associated with UTIs. Estrogen therapy has also been suggested as a potential treatment option for UTIs, particularly in postmenopausal women. Trimethoprim-sulfamethoxazole or trimethoprim is recommended as first-line therapy for uncomplicated UTIs. The choice of drug and therapy for UTIs depends on the severity of the infection, the causative organism, and the presence of antibiotic resistance.Preventive measures encompass pre-transplant evaluation, perioperative strategies, post-transplant follow-up, and vaccination. A multidisciplinary approach involving transplant specialists, infectious disease experts, pharmacists, and patient engagement is vital for successful care. The future of UTI management lies in ongoing research, exploring personalized medicine, novel therapies, and innovative prevention strategies. By implementing these strategies and advancing research, healthcare providers can improve graft and patient survival, enhancing the quality of care for renal transplant recipients.

Enhanced Recovery after Renal Transplantation Decreases Recipients' Urological Complications and Hospital Stay: A Systematic Review and Meta-Analysis.

The objective of this study was to compare enhanced recovery after surgery (ERAS) against traditional perioperative care for renal transplant recipients. Outcome measures included complications, length of stay (LOS), readmission rates, graft and patient survival up to one-year post-transplant. We initially screened Medline, Cochrane, Scopus, Embase and Web of Science databases. We identified 3029 records. From these, 114 full texts were scrutinized for inclusion. Finally, 10 studies were included in the meta-analysis corresponding to 2037 renal transplant recipients. ERAS resulted in lower incidence of urological complications (95CI: 0.276, 0.855) (I2 = 53.08%) compared to traditional perioperative practice. This referred to ureteric stenoses (95CI: 0.186–0.868) (I2 = 0%) and urinary tract infections (95CI: 0.230–0.978) (I2 = 71.55%). ERAS decreased recipients’ LOS (95CI: −2.876, −0.835) (I2 = 86.55%). Compared to standard practice, ERAS protocols did not increase unplanned readmissions (95CI:0.800, 1.680) (I2 = 0%). Up to one-year post-transplant, graft survival rates were similar across the ERAS and the control groups (95CI:0.420, 1.722) (I2 = 0%). There was also no difference in recipients’ one-year post-transplant survival (95CI:0.162, 3.586) (I2 = 0%). Our results suggest that ERAS protocols can be safely incorporated in the perioperative care of renal transplant recipients, decrease their urological complications and shorten their length of hospital stay without affecting unplanned readmission rates.

Transplant-related Symptom Clusters in Renal Transplant Recipients.

Renal transplant recipients experience multiple symptoms, but complex relationships among these symptoms remain poorly understood. To explore the existence of symptom clusters in renal transplant recipients. A total of 295 renal transplant recipients were recruited in a hospital in Tianjin from October 2017 to January 2018. The participants completed the symptom questionnaire that assessed three symptom dimensions of 62 symptoms. Exploratory factor analysis was performed to identify symptom clusters. Five symptom clusters were extracted through exploratory factor analysis: emotional-sleep symptom cluster, pain-gastrointestinal symptom cluster, immune-related symptom cluster, lack of energy symptom cluster, and visual dysfunction symptom cluster, which explained 50.53% of the variance of symptom experience. Renal transplant recipients experienced a complex series of symptoms, and some symptoms related to one another formed a symptom cluster. Adopting a symptom cluster approach has the potential to remarkably enhance symptom assessment and nursing care for renal transplant recipients.

PUK26 MULTIDISCIPLINARY CARE OF RENAL TRANSPLANT RECIPIENTS: THE ROLE OF CLINICAL PHARMACIST

There are limited data about the role of clinical Pharmacist as a direct care provider for renal transplant recipients, especially in the Arab world. This study aims at describing a single center experience in providing clinical pharmacy services for recently kidney transplanted patients. A pilot descriptive study has been conducted from January 2019 till April 2019 in the renal transplant unit of the Armed forces hospitals southern region, Saudi Arabia. A clinical Pharmacist attended the renal transplant selection committee weekly meetings, attended daily rounds, provided necessary drug therapy recommendations, responded to drug information requests, conducted medication reconciliation upon patients' admission and discharge and provided verbal and written pre and post-transplant patient education (during admission, post-transplant clinics visits and through social media) During the study period, 21 patients transplanted in the unit (52.4% females, mean age = 40.5 years SD=17.35 years). The clinical Pharmacist had 141 recommendations (6.7 recommendations per patient). Sixty-two recommendations (44%) were medication reconciliation related, 11 recommendations (7.8%) based on drug information requests while the remaining 48.2% were pharmacotherapeutic recommendations provided during daily rounds. Clinical pharmacist's recommendations involved immunosuppressive agents (34.8%), Antimicrobials (13.8%), bone-mineral disorders medications (11.5%), Electrolytes (9.4%), Anemia management medications (8.6%), Anticoagulants (4.3%), Antihypertensives (3.6%), antidiabetics (2.9%) and Miscellaneous medications (11.1%). The recommendations involved medications doses increases (38.2%),medications added (25%), doses reductions (16.2%), therapeutic drug monitoring lab requests (11.8%), medication discontinuation (5.9%) and medication substitution (2.9%). The overall physicians' acceptance rate of clinical Pharmacist's recommendations was 95.6%. The study findings suggest that clinical pharmacists could positively impact the quality of care for renal transplant recipients and promote their medication safety.

Renal Transplantation Is Associated with Increased Complications Following Spinal Fusion Operations: Analysis of a National Database

Improved postoperative care for renal transplant recipients has advanced both duration and overall quality of life. However, degenerative spinal pathology is increasingly prevalent after transplant. Outcomes following spinal fusion among the renal transplant population in the United States are rarely addressed. The Healthcare Cost and Utilization Project National Inpatient Sample database was employed. Cases in years 2008-2014 for patients ≥18 years old receiving spinal fusion, exploration/decompression, and/or spinal revision/re-fusion surgeries were included. Cases were divided into kidney transplant recipients (KTR) and non-kidney transplant recipients. Complications, demographics, and socioeconomic outcomes were compared between cohorts. Of 579,726 patients who met inclusion criteria, 685 (0.1%) were KTRs. The KTR population was older and included more men compared with the non-kidney transplant recipient population (60.1 years vs. 56.6 years, P < 0.001; 58% male vs. 45.5% male, P < 0.001). KTRs experienced higher total complication rates (29.8% vs. 18.9%, P < 0.001). Prevalence of acute posthemorrhagic anemia and need for transfusion was markedly higher for KTRs (15.8% vs. 9.1%, P < 0.001; 13.6% vs. 6.2%, P < 0.001). Multivariate analysis revealed longer length of stay (median 1.23 days, interquartile range 0.94-1.53, P < 0.001), lower routine discharge (odds ratio= 0.57, 95% confidence interval 0.48-0.69, P < 0.001), and higher discharge to alternative care facilities (odds ratio= 1.91, 95% confidence interval 1.57-2.33, P < 0.001) for KTRs. The inpatient course for KTRs undergoing spinal operations was significantly costlier ($87,445 vs. $71,589, P < 0.001). History of renal transplant was associated with increased inpatient medical and socioeconomic complications following spinal fusion. Physicians and patients must understand and respect the potentially increased perioperative challenges facing KTRs.

SP793Costs of long-term post-transplant care in renal transplant recipients

SP793Costs of long-term post-transplant care in renal transplant recipients

Barriers to vaccination in renal transplant recipients.

Vaccine-preventable diseases remain at the forefront of challenges in the long-term care of renal transplant recipients (RTR). Although global vaccination campaigns targeting patients with end-stage renal disease or RTR are standard, rates of vaccination among renal transplant candidates and RTRs remain suboptimal. We highlight the multifactorial barriers leading to low vaccination rates in this vulnerable population.

Renal transplantation in 2014: renal transplantation-reducing risk and improving outcome.

Several studies published in 2014 might facilitate improvements in the treatment and long-term care of renal transplant recipients. The potential risks of living kidney donation, the efficacy and safety of alemtuzumab-based induction therapy, and the treatment of chronic hepatitis E virus infection have been addressed.

Comparison of 12-Hour Creatinine Clearance and Estimated Glomerular Filtration Rate in Renal Transplant Recipients

Glomerular filtration rate (GFR) is an essential clinical assessment of renal function post-renal transplantation. Creatinine clearance (CrCl) measured over 12 h and estimated GFR (e-GFR) (calculated by the Modification of Diet in Renal Disease equation) were compared in 28 stable renal transplant recipients (RTRs). This single center study included 14 African American (AA) and 14 Caucasian (CC) recipients. The 12-h creatinine clearance (CrCl-12 h) was determined by monitored urine collection and by e-GFR on two occasions (two phases) separated by at least 2 weeks. Statistics included mixed model analysis of CrCl-12 h and e-GFR relative to race, phase, and difference between parameters. In the first phase, the e-GFR was higher in AA males (58.4 ± 14.8 mL/min) than the CC males (46.2 ± 10.2 mL/min) (p = 0.032), whereas the CrCl-12 h of AA males (70.8 ± 8.7 mL/min) and CC males (63.3 ± 21.7 mL/min) was not different (p = 0.740). During the second phase, the e-GFR in AA and CC RTRs was 55.4 ± 10.1 mL/min and 47.6 ± 10.7 mL/min (p = 0.117), respectively, whereas CrCl-12 h in AAs was 64.71 ± 17.9 mL/min and in CCs was 62.0 ± 14.9 mL/min (p = 1.000). The CrCl-12 h was higher than the e-GFR (p < 0.001) irrespective of race or phase. CrCl-12 h was not different on both occasions (p = 0.289) in all the patients. CrCl-12 h was consistently greater than e-GFR. The difference between these e-GFR estimates may have an importance in the care of RTRs.

Tacrolimus in transplant rejection

Introduction: Renal transplantation is the best therapy for patients with end-stage renal disease. To avoid graft rejection, adequate immunosuppressive therapy is crucial. Tacrolimus is approved for prophylaxis of transplant rejection in liver, kidney or heart allograft recipients and for the treatment of allograft rejection resistant to treatment with other immunosuppressive medicinal products.Areas covered: The objective of this review is to summarize the clinical efficacy of tacrolimus in renal transplantation with special emphasis on acute rejection, refractory rejection and nephrotoxicity and post-transplant diabetes mellitus as typical adverse effects of the drug.Expert opinion: Since its approval in 1994, tacrolimus has proven its efficacy as a cornerstone of modern immunosuppressive therapy not only in numerous randomized clinical trials but also in standard clinical care. Compared with cyclosporine, the use of tacrolimus in renal transplant recipients is associated with a reduced risk for acute rejection, a reduction in the occurrence of steroid-resistant rejection and a better graft function. The avoidance of nephrotoxicity and especially post-transplant diabetes mellitus are of major interest in long-term care of renal transplant recipients.

Utility and cost of a renal transplant transition clinic

Successful transition from paediatric-centred to adult-oriented healthcare positively influences health outcomes for youth with chronic illness. The primary objective is to evaluate outcomes pre- and post provision of multidisciplinary transition clinic (TC) care to renal transplant recipients. We compared patient and allograft survival in renal transplant recipients at British Columbia Children's Hospital who received care within a transition clinic (TC) to a cohort of patients transferred prior to establishment of the TC, pre-TC (PTC) in 2007. Baseline characteristics, allograft function, and survival data were collected prospectively via a validated provincial database for 2 years posttransfer. We also estimated and compared the average yearly per-patient cost during the 2-year follow-up period. Thirty-three patients were transferred (PTC) and 12 transitioned (TC). In the PTC cohort, there was a combined poor outcome (death or allograft loss) incidence of 24% within 2 years posttransfer compared with no death or allograft loss in the TC cohort. Cost estimates indicate the average yearly per-patient cost was Canadian dollars (CAD) $17,127-$38,909 for the PTC and CAD $11,380-$34,312 for the TC cohort. For PTC patients who lost their allograft and returned to dialysis, the per-patient cost was CAD $40,956-$61,470. Our results indicate improved allograft and patient survival posttransfer of care in renal transplant recipients who attended TCs, and we found that providing TCs is economically feasible.

Evaluation of Dietetic Advice for Modification of Cardiovascular Disease Risk Factors in Renal Transplant Recipients

To investigate the effect of dietitian involvement in a multidisciplinary lifestyle intervention comparing risk factor modification for cardiovascular disease with standard posttransplant care in renal transplant recipients (RTR) with abnormal glucose tolerance (AGT). Randomized controlled trial. Hospital outpatient department. Adult RTR with AGT. RTR with AGT were randomized to a lifestyle intervention that consisted of either regular consultations with the dietitian and multidisciplinary team or standard care. Dietary intake, physical activity (PA) levels, cardiorespiratory fitness (CF), and anthropometry. Total fat and percent saturated fat intake rates were significantly lower in the intervention group as compared with the control group at 2-year follow-up, 54 g (16 to 105 g) versus 65 g (34 to 118 g), P = .01 and 10% (5% to 17%) versus 13% (4% to 20%), P = .05., respectively. There was a trend for an overweight (but not obese) individual to lose more weight in the intervention group (4% loss vs. a gain of 0.25% at the 2-year follow-up). Overall, RTR were significantly less fit than age- and gender-matched controls, mean peak oxygen uptake was 19.42 ± 7.09 mL/kg per minute versus 28.35 ± 8.80 mL/kg per minute, P = .000. Simple exercise advice was not associated with any improvement in total PA or CF in either group at the 2-year follow-up. Dietary advice can contribute to healthier eating habits and a trend for weight loss in RTR with AGT. These improvements in conjunction with multidisciplinary care and pharmacological treatment can lead to improvements in cardiovascular risk factors such as lipid profile. Simple advice to increase PA was not effective in improving CF and other measures are needed.

Pharmaceutical care for renal transplant recipients

Pharmaceutical care for renal transplant recipients

Assessment of Efficacy and Safety of FK778 in Comparison With Standard Care in Renal Transplant Recipients With Untreated BK Nephropathy

BK polyomavirus infection has been reported in 10% to 60% of renal transplant recipients with progression to BK nephropathy (BKN) occurring in 1% to 5% of patients. Graft loss occurs in up to 60% of renal transplant recipients with BKN. Because BK polyomavirus infection is believed, in part, to be a manifestation of overimmunosuppression, the current standard of care involves the reduction of immunosuppressants. This strategy has been associated with clearance of viral load, preservation of renal function, and improvement in graft survival; however, this may come at a risk of rejection. A safe and effective immunosuppressive agent that does not predispose to viral infection is needed in transplantation. In a phase 2, proof-of-concept, randomized, open-label, parallel-group, 6-month study in renal transplant patients, FK778 (an investigational immunosuppressant from the malononitrilamides class) was compared with the current standard of care (reduction of immunosuppression) for treatment of newly diagnosed or untreated BKN, which was confirmed by renal biopsy. Demographic characteristics were similar between the two groups, except there were numerically more females in the FK778 group than in the standard care group. Although the treatment with FK778 decreased BK viral load in this study, it was associated with a less favorable rejection profile and renal function and a higher incidence of serious adverse events compared with reduction of immunosuppression. Data from this study are consistent with the findings of previous studies that found no benefit of drug therapy in the treatment of BKN in kidney transplant recipients.

Similar Outcomes for Canadian Renal Transplant Recipients Followed Up in Transplant Centers and Satellite Clinics

A significant proportion of long-term care for renal transplant recipients (RTRs) in Canada is provided by community nephrologists in satellite clinics (SCs). The outcomes of RTRs followed up in SCs have not been formally compared with those followed up in transplant centers (TCs). This multicenter retrospective study from 13 TCs and SCs across Canada compared patient and graft outcomes in RTRs with a functioning graft more than or equal to 18 months. Data were abstracted at 6 to 18 months posttransplantation, and at last visit (if >18 months). Patients were stratified in a 1:1 ratio between TCs and SCs, and by a 3:1 ratio between cyclosporine A and tacrolimus. The primary outcome was change (Δ) in Modification of Diet in Renal Disease estimated glomerular filtration rate (eGFR) from 6 to 18 months posttransplantation (ΔeGFRM18-6). Secondary outcomes included the prevalence of hyperlipidemia, diabetes, and hypertension. A total of 264 RTRs followed at TCs and SCs demonstrated broad similarity in baseline recipient and donor characteristics. ΔeGFRM18-6 were similar for TCs versus SCs and better for tacrolimus versus cyclosporine A (P=0.022). There was no difference in lipid levels between TCs and SCs during 6 to 18 months, although low-density lipoprotein cholesterol was lower in SCs versus TCs at most recent visit (2.6 vs. 2.3 mmol/L; P=0.003). Fasting blood glucose levels were similar in TCs and SCs. Comparable target blood pressure levels were achieved, and the prevalence of hypertension was similar for both TCs and SCs at all time points. Short-term graft and patient outcomes are similar in TC and SC RTRs, supporting the feasibility of follow-up patient care outside major TCs.

The KDIGO review of the care of renal transplant recipient

This review highlights the key messages from the KDIGO (Kidney Disease: Improving Global Outcomes) clinical practice guidelines for care of kidney transplant recipients, which were written to be global guidelines irrespective of the regulatory, fiscal, cultural, socioeconomic, or geographical environment. The distillation of 3168 randomized control trials, 7543 cohort studies, and 1609 reviews led to recommendations rated by the strength of supporting evidence and the quality of the data from A to D. Despite this, the quality of the evidence is surprisingly low for the majority of decisions that are routinely taken in all transplant units throughout the world, highlighting the needs for properly designed randomized controlled trials. The principle areas covered in the guidelines include immunosuppression, management of acute rejection, monitoring of the patient and graft, chronic allograft injury, kidney biopsy, nonadherence, vaccination, infectious diseases, cardiovascular risk management, malignancy, bone disease, pediatric growth, lifestyle, fertility, and mental health. This review highlights a number of these areas for consideration focusing on the different types of evidence that we use in daily clinical practice.

The KDIGO Clinical Practice Guidelines for the Care of Kidney Transplant Recipients

The clinical guideline for care of renal transplant recipients was written by a committee of 15 people from nine countries, supported by an evidence review team The scope of the review was care of the patient after a renal transplant-not evaluation or selection of recipients and donors, focusing on the issue specific to the immunosuppressed transplant patient. A total of 12,327 articles comprising 3168 randomized controlled trials, 7543 cohort studies, and 1609 reviews were selected by a formal search. Each article was formally evaluated for the quality of the data from A to D. A consistent set of statements were based on the strength of the evidence. Level 1 evidence: "we recommend" means that if you were a patient, most people would want to do this; if a clinician, you should recommend this course of action to most patients; and if a policy maker, you should adopt this as a reasonable standard. Level 2 evidence: "we suggest" means the majority of patients would want do this; to the clinician, it means that different solutions may well be needed for different patients; whereas to the health policy maker, this is a strong warning to engage stakeholders in the creation of a particular local policy. Because 69% of the advice is "suggested" on the basis of level C or D evidence, one outcome of this work is to make it clear where the current evidence for clinical decisions runs out of data.

Cyclosporine Versus Tacrolimus in Immunosuppressive Maintenance Regimens in Renal Transplants in Brazil: Survival Analysis from 2000 to 2004

In Brazil, the National Health System (SUS) is responsible for almost all renal transplants. SUS protocols recommend using cyclosporine, in association with azathioprine and corticosteroids, to maintain the immunosuppression that is essential for successful renal transplant. Alternatively, cyclosporine can be replaced by tacrolimus. To evaluate the effectiveness of therapeutic schema involving cyclosporine or tacrolimus after renal transplant during a 60-month follow-up period. A historical cohort study, from 2000 to 2004, was conducted using 5686 patients who underwent renal transplant and received cyclosporine or tacrolimus. Uni - and multivariate analyses were performed using the Cox model to examine factors associated with progression to treatment failure. Most of the patients were male, aged 38 years or older, for whom the most frequent primary diagnosis of chronic renal failure (CRF) was glomerulonephritis/nephritis. Higher risk of treatment failure was associated with: therapeutic regimen (tacrolimus, HR 1.38, 95% CI 1.14 to 1.67), patient age at transplantation (additional year, HR 1.01, 95% CI 1.00 to 1.02), donor type (deceased, HR 1.60, 95% CI 1.35 to 1.89), median time of dialysis prior to transplantation (>24 mo, HR 1.29, 95% CI 1.09 to 1.52), and primary CRF diagnosis (diabetes, HR 1.54, 95% CI 1.09 to 2.17). The risk of treatment failure of patients receiving tacrolimus was observed to be 1.38 times that of those receiving cyclosporine, after adjusting the model for possible confounding factors such as patient sex, patient age, graft origin, prior time of dialysis, and cause of CRF. Our results were obtained from an observational study, and further studies are necessary to evaluate whether compliance with SUS clinical protocols could result in more effective care for renal transplant recipients.

The D&amp;T Report

The D&amp;T Report

Adiponectin is associated with cardiovascular disease in male renal transplant recipients: baseline results from the LANDMARK 2 study

BackgroundAdiponectin is a major adipocyte-derived protein with insulin-sensitizing, anti-inflammatory and anti-atherogenic properties. Adiponectin levels correlate inversely with renal function and higher levels are predictive of lower cardiovascular disease (CVD) in patients with normal renal function and chronic kidney disease. No data exists on the association between adiponectin and CVD in renal transplant recipients (RTR).MethodsStandard biochemistry, clinical data and adiponectin were collected from 137 RTR recruited to the LANDMARK 2 study at baseline. The LANDMARK 2 study is an ongoing randomized controlled study that compares the outcome of aggressive risk factor modification for cardiovascular disease versus standard post-transplant care in renal transplant recipients with impaired glucose tolerance or diabetes mellitus.ResultsMean patient age was 53.4 ± 12 years and the median post-transplantation period was 5 (0.5-31.9) years. Mean serum adiponectin level was 12.3 ± 7.1 μg/mL. On univariate analysis, adiponectin was positively associated with female gender (P = 0.01) and serum high-density lipoprotein (HDL) concentration (P < 0.001), and inversely with body mass index (P = 0.009), metabolic syndrome (P = 0.047), abnormal glucose tolerance (P = 0.01), C-reactive protein (P = 0.001) and serum triglyceride (P < 0.001). On stepwise multivariate analysis, adiponectin in males was negatively correlated with combined baseline CVD (P = 0.03), waist-hip ratio (P = 0.003) and glomerular filtration rate (P = 0.046), and positively with HDL (P < 0.001). In contrast, in females adiponectin was inversely associated with C-reactive protein (P = 0.001) and serum triglyceride.ConclusionIn conclusion, adiponectin is positively correlated with inflammation, dyslipidemia and abnormal glucose tolerance in RTR. Furthermore, hypoadiponectinemia correlated with increased baseline CVD in male RTR.