Critical Care Therapy Research Articles

Feeding should be individualized in the critically ill patients.

Any critical care therapy requires individual adaptation, despite standardization of the concepts supporting them. Among these therapies, nutrition care has been repeatedly shown to influence clinical outcome. Individualized feeding is the next needed step towards optimal global critical care. Both underfeeding and overfeeding generate complications and should be prevented. The long forgotten endogenous energy production, maximal during the first 3 to 4 days, should be integrated in the nutrition plan, through a slow progression of feeding, as full feeding may result in early overfeeding. Accurate and repeated indirect calorimetry is becoming possible thanks to the recent development of a reliable, easy to use and affordable indirect calorimeter. The optimal timing of the prescription of the measured energy expenditure values as goal remains to be determined. Optimal protein prescription remains difficult as no clinically available tool has yet been identified reflecting the body needs. Although energy expenditure can now be measured, we miss indicators of early endogenous energy production and of protein needs. A pragmatic ramping up of extrinsic energy provision by nutrition support reduces the risk of overfeeding-related adverse effects.

Changes in acute blood purification therapy in critical care: republication of the article published in the Japanese Journal of Artificial Organs.

Acute blood purification therapy is an essential artificial organ in critical care. In the review article, looking back on the history, we describe our present knowledge and techniques of acute blood purification therapy in critical care. The topics include continuous hemodiafiltration (CHDF), online HDF as an artificial liver support, blood purification therapy aiming to remove pathogenic substances of sepsis, a procedure for connecting a CRRT device into an extra-corporeal membrane oxygenation circuit, and replacement fluid for CHDF. We also raise remaining issues and clarify the future direction of acute blood purification therapy in critical care. This review was created based on a translation of the Japanese review written in the Japanese Journal of Artificial Organs in 2017 (Vol. 46, No. 1, pp. 67-70), with adding some references.

Renal Replacement Therapy in Critical Care: When to Start?

Aside from absolute indications, the optimal timing of renal replacement therapy (RRT) in critical care is unknown. In this review, we discuss initiation of RRT in relation to both severity of acute kidney injury (AKI) and fluid accumulation. Results from studies of early vs. late RRT are conflicting, and no definitive conclusions have been made. Observational data points to fluid accumulation as a detrimental factor in critical illness and recent studies have shown that early fluid removal with RRT is feasible and could potentially improve survival. There is a gap in the knowledge regarding when to initiate RRT in the absence of acute life-threatening complications. Recent studies of fluid accumulation in critically ill patients indicate the importance of avoiding fluid overload, and RRT might play an increasing role in the management of fluid balance in critical care.

IDEAL timing of renal replacement therapy in critical care.

The IDEAL-ICU study reports no mortality benefit of early versus delayed initiation of renal replacement therapy (RRT) in patients with early septic shock and acute kidney injury. In the delayed initiation group, 17% of patients required emergency RRT but more than one-third spontaneously recovered renal function and did not require RRT.

Resuscitation fluids.

Intravenous fluid administration is a fundamental therapy in critical care, yet key questions remain unanswered regarding optimal fluid composition and dose. This review evaluates recent evidence regarding the effects of fluid resuscitation on pathophysiology, organ function, and clinical outcomes for critically ill patients. Recent findings suggest that intravenous fluid composition affects risk of kidney injury and death for critically ill adults. Generally, the risk of kidney injury and death appears to be greater with semisynthetic colloids compared with crystalloids, and with 0.9% sodium chloride compared with balanced crystalloids. Whether a liberal, restrictive, or hemodynamic responsiveness-guided approach to fluid dosing improves outcomes during sepsis or major surgery remains uncertain. As evidence on fluid resuscitation evolves, a reasonable approach would be to use primarily balanced crystalloids, consider 2-3 l for initial fluid resuscitation of hypovolemic or distributive shock, and use measures of anticipated hemodynamic response to guide further fluid administration.

Management of calciphylaxis in a burn center: A case series and review of the literature

Calciphylaxis is a rare, necrotizing skin disorder usually associated with kidney disease, but also caused by many other systemic illnesses. This disease is associated with mortality rates as high as 80% at 1year. We present the demographic and clinical data of nine patients with calciphylaxis treated at our burn center over a 10year period. We review the literature on the clinical presentation, pathophysiology, diagnosis and treatment of this rare disease. We propose that these patients be treated similar to patients with thermal burn injury; meaning intensive wound care, surgical management, critical care and physical therapy. Burn centers are uniquely capable of caring for these incredibly complex patients due to their experience in managing patients with extensive skin and soft tissue defects, wounds and diseases.

FIRST-line support for Assistance in Breathing in Children (FIRST-ABC): a multicentre pilot randomised controlled trial of high-flow nasal cannula therapy versus continuous positive airway pressure in paediatric critical care

BackgroundAlthough high-flow nasal cannula therapy (HFNC) has become a popular mode of non-invasive respiratory support (NRS) in critically ill children, there are no randomised controlled trials (RCTs) comparing it with continuous positive airway pressure (CPAP). We performed a pilot RCT to explore the feasibility, and inform the design and conduct, of a future large pragmatic RCT comparing HFNC and CPAP in paediatric critical care.MethodsIn this multi-centre pilot RCT, eligible patients were recruited to either Group A (step-up NRS) or Group B (step-down NRS). Participants were randomised (1:1) using sealed opaque envelopes to either CPAP or HFNC as their first-line mode of NRS. Consent was sought after randomisation in emergency situations. The primary study outcomes were related to feasibility (number of eligible patients in each group, proportion of eligible patients randomised, consent rate, and measures of adherence to study algorithms). Data were collected on safety and a range of patient outcomes in order to inform the choice of a primary outcome measure for the future RCT.ResultsOverall, 121/254 eligible patients (47.6%) were randomised (Group A 60%, Group B 44.2%) over a 10-month period (recruitment rate for Group A, 1 patient/site/month; Group B, 2.8 patients/site/month). In Group A, consent was obtained in 29/33 parents/guardians approached (87.9%), while in Group B 84/118 consented (71.2%). Intention-to-treat analysis included 113 patients (HFNC 59, CPAP 54). Most reported adverse events were mild/moderate (HFNC 8/59, CPAP 9/54). More patients switched treatment from HFNC to CPAP (Group A: 7/16, 44%; Group B: 9/43, 21%) than from CPAP to HFNC (Group A: 3/13, 23%; Group B: 5/41, 12%). Intubation occurred within 72 h in 15/59 (25.4%) of HFNC patients and 10/54 (18.5%) of CPAP patients (p = 0.38). HFNC patients experienced fewer ventilator-free days at day 28 (Group A: 19.6 vs. 23.5; Group B: 21.8 vs. 22.2).ConclusionsOur pilot trial confirms that, following minor changes to consent procedures and treatment algorithms, it is feasible to conduct a large national RCT of non-invasive respiratory support in the paediatric critical care setting in both step-up and step-down NRS patients.Trial registrationclinicaltrials.gov, NCT02612415. Registered on 23 November 2015.

Prophylactic Antimicrobial Therapy for Acute Aspiration Pneumonitis.

Prophylactic antimicrobial therapy is frequently prescribed for acute aspiration pneumonitis, with the intent of preventing the development of aspiration pneumonia. However, few clinical studies have examined the benefits and harms of this practice. A retrospective cohort study design was used to compare outcomes of patients with aspiration pneumonitis who received prophylactic antimicrobial therapy with those managed with supportive care only during the initial 2 days following macroaspiration. The primary outcome was in-hospital mortality within 30 days. Secondary outcomes included transfer to critical care and antimicrobial therapy received between days 3 and 14 following macroaspiration including escalation of therapy and antibiotic-free days. Among 1483 patients reviewed, 200 met the case definition for acute aspiration pneumonitis, including 76 (38%) who received prophylactic antimicrobial therapy and 124 (62%) who received supportive management only. After adjusting for patient-level predictors, antimicrobial prophylaxis was not associated with any improvement in mortality (odds ratio, 0.9; 95% confidence interval [CI], 0.4-1.7; P = .7). Patients receiving prophylactic antimicrobial therapy were no less likely to require transfer to critical care (5% vs 6%; P = .7) and subsequently received more frequent escalation of antibiotic therapy (8% vs 1%; P = .002) and fewer antibiotic-free days (7.5 vs 10.9; P < .0001). Prophylactic antimicrobial therapy for patients with acute aspiration pneumonitis does not offer clinical benefit and may generate antibiotic selective pressures that results in the need for escalation of antibiotic therapy among those who develop aspiration pneumonia.

Renal replacement therapy in critical care in patients with acute kidney injury

Renal replacement therapy in critical care in patients with acute kidney injury

Expanding role of renal replacement therapy in a tertiary care Picu : Unit experience

Background : The role of renal replacement therapy (RRT) in critical care is expanding. It is the cornerstone in the management of critically ill children. Continuous RRT is a mainstay of treatment in PICU for acute kidney injury (AKI) due to well-maintained hemodynamic stability with slow predictable fluid and solute removal. Apart from the classic indications RRT plays a significant role in the treatment of many other disease conditions such as septic shock and other organ-supportive strategies. Methods : We conducted a retrospective analysis of all the children who underwent RRT for critical care indications over a period from July 2015 to July 2017 at Rainbow Children’s Hospital, Marathahalli, Bangalore. Results : A total of 24 children underwent RRT over a period of 2 years with 12 males (50%) and 12 females (50%). Out of these 5 children (20.8%) had background of chronic kidney disease. Mean age of children who underwent RRT was 6 years (range:4 months-16 years). Sepsis with septic shock was the diagnosis most commonly associated to needing RRT (58.3%). The most common clinical condition associated with acute kidney injury was hemodynamic instability (58%), followed by multi-organ dysfunction syndrome (41%). The most common indication for initiating RRT was Acute Kidney Injury stage 2 with fluid overload >10% (as defined by KDIGO criteria) in 50% of the cases followed by severe metabolic acidosis refractory to medical therapy (29%). Eleven (45.8%) children who underwent RRT had Multi-organ dysfunction. There were no significant complications associated to initiation of RRT. Fifty- four percent of children survived. Among the children who died 81% had Multi-organ dysfunction syndrome. Three children (23%) required intermittent hemodialysis on follow up for complete recovery. Continuous renal replacement Therapy (CRRT) was done in 11 children (45.8%). The median duration of CRRT was 30 hours with the longest duration being 194 hours. Most common mode of CRRT used was Continuous venovenous hemodiafiltration (CVVHDF) . Newer hybrid techniques like Sustained low efficiency dialysis (SLED) was used in 5 patients (20%) with complete recovery noted during PICU stay. Conclusion : We present a diverse population of pediatric patients requiring RRT. Sepsis with septic shock was the most common diagnosis requiring RRT in our study population. CVVHDF was the common mode of RRT we used in our unit followed by newer techniques like SLED. We noticed hemodynamic instability and multi-organ dysfunction syndrome are the most common clinical conditions associated with acute kidney injury in our population. We did not observe any significant complications associated with initiation for RRT which indicates CRRT is safe in hemodynamic unstable patients. We observed that new therapies and techniques can provide supportive treatment beyond the classic renal indications.

Clinical study of blood purification therapy in critical care in Japan: results from the survey research of the Japan Society for Blood Purification in Critical Care in 2013.

To clarify the clinical status of blood purification therapy (BPT) in critical care in Japan, we conducted a cohort study using data from a nationwide registry of the Japan Society for Blood Purification in Critical Care in 2013. We enrolled 2227 patients treated with BPT (female, 39.1%; mean age, 65.5±12.1years) in the intensive care units of 43 facilities. Patient characteristics, modes of BPT, and survival rate for each disease were investigated. In total, BPT was performed 3053 times. Continuous renal replacement therapy (CRRT) (57.9%) was the most common mode of BPT, followed by intermittent renal replacement therapy (20.2%) and direct hemoperfusion with the polymyxin B-immobilized fiber column (PMX-DHP) (11.5%). Nafamostat mesilate (84.9%) was most frequently used as the anticoagulant. The 28-day survival rate was 56.8% in all patients. The most common mode for acute kidney injury (AKI) and multiple organ failure was CRRT, while PMX-DHP and CRRT were most common for sepsis. There was no significant difference in survival rates among AKI stages 1-3. Survival rate (38.3%) was significantly lower in patients with acute lung injury (ALI) than in those with multiple organ failure (41.8%) and those with sepsis (46.6%). Multivariate regression analysis revealed that the APACHE II score and the presence of acute ALI and acute hepatic failure were significantly associated with death. This large-scale cohort study showed the clinical status of BPT in Japan. Further investigations are required to clarify the efficacy of BPT for critically ill patients.

Managing dysphagia in patients with neurological conditions

British Journal of Neuroscience NursingVol. 13, No. 3 CommentManaging dysphagia in patients with neurological conditionsRosie ThompsonRosie ThompsonSearch for more papers by this authorRosie ThompsonPublished Online:14 Jul 2017https://doi.org/10.12968/bjnn.2017.13.3.106AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Fletcher J (2015) Dealing with dysphagia, a multi-disciplinary approach. Nursing and Residential Care 17(8): 430-432. https://doi.org/10.12968/nrec.2015.17.8.430 Google ScholarHeadway (2010) Dysphagia after brain injury. https://tinyurl.com/y8qwu3df (accessed 21 June 2017) Google ScholarLancaster J (2015) Dysphagia: its nature, assessment and management. Br J Community Nurs Suppl Nutrition: S28-32. https://doi.org/http://dx.doi.org/10.12968/bjcn.2015.20.Sup6a.S28 Link, Google ScholarMarsh S, Ross N, Pittard A (2011) Neuromuscular disorders and anaesthesia. Part 1: generic anaesthetic management. Contin Educ Anaesth Crit Care Pain 11(4): 115-8. doi: https://doi.org/https://doi.org/10.1093/bjaceaccp/mkr020 Crossref, Google ScholarMalhi H (2016) Dysphagia: warning signs and management. Br J Nurs 25(10): 546–9. https://doi.org/http://dx.doi.org/10.12968/bjon.2016.25.10.546 Link, Google ScholarMiles A, McFarlane M, Kainth P, Parmar P (2014) Interdisciplinary management of dysphagia. Nursing and Residential Care. 16(10): 561-7. https://doi.org/https://doi.org/10.12968/nrec.2014.16.10.561 Link, Google ScholarMyatt R (2015) Nursing care of patients with a temporary tracheostomy. Nurs Stand 29(26): 42–9. https://doi.org/https://doi.org/10.7748/ns.29.26.42.e9742 Crossref, Google ScholarNational Institute for Health and Care Excellence (2006) Nutrition Support for Adults: Oral nutrition support, enteral tube feeding, and parenteral nutrition [CG32] https://tinyurl.com/kz8nu6h (accessed 21 June 2017) Google ScholarNational Patient Safety Agency (2011) Dysphagia Diet Food Texture Descriptors. https://tinyurl.com/l4o2say (accessed 21 June 2017) Google ScholarNational Tracheostomy Safety Project (2013) NTSP Manual. https://tinyurl.com/y7qy8jzg (accessed 21 June 2017) Google ScholarNutrition and Diet Resources (2014) Easier Swallowing: Fluid Thickening Guide. Nutrition and Diet Resources, Glasgow Google ScholarRoyal College of Physicians and British Society of Rehabilitation Medicine (2003) Rehabilitation following acquired brain injury: national clinical guidelines. RCP BSRM, London Google ScholarRoyal College of Physicians, British Society of Gastroenterology (2010) Oral Feeding Difficulties and Dilemmas: A Guide to Practical Care, Particularly Towards the End of Life. Royal College of Physicians, London Google ScholarRoyal College of Speech and Language Therapists (2013) RCSLT Resource Manual for Commissioning and Planning Services for SLCN: Dysphagia. RCSLT, London. http://tinyurl.com/ybdlszy3 (accessed 21 June 2017) Google ScholarRoyal College of Speech and Language Therapists (2014) Position paper. Speech and language therapy in adult critical care. http://tinyurl.com/y7lu853l (accessed 21 June 2017) Google ScholarScottish Intercollegiate Guidelines Network (2010) Management of Patients with Stroke: Identification and Management of Dysphagia. A National Clinical Guideline. https://tinyurl.com/y86mfoso (accessed 21 June 2017) Google ScholarSmithard DG (2015) Dysphagia: prevalence, management and the community nurse. Community Pract 88(10): 32–5 Google ScholarTanton M (2010) Developing a screening tool and training package to identify dysphagia in all settings. Nurs Times 106(15): 18–20 Google Scholar FiguresReferencesRelatedDetails 2 June 2017Volume 13Issue 3ISSN (print): 1747-0307ISSN (online): 2052-2800 Metrics History Published online 14 July 2017 Published in print 2 June 2017 Information© MA Healthcare LimitedPDF download

Renal replacement therapy in critical care

Renal replacement therapy in critical care

Physiotherapy on ECMO: Mobility and beyond

Intensive care unit-acquired weakness is a common sequela of critical illness and is associated with deficits in physical strength, functional performance, and associated health-related quality of life. 1–3 Early rehabilitation in the intensive care unit (ICU) is recognised as safe and feasible. 4,5 Maintaining and restoring musculoskeletal strength and function is recognised as an essential element of therapy in critical care. 3 Active rehabilitation of patients with femoral access veno-venous extracorporeal membrane oxygenation (VV ECMO) has been deemed a high-risk procedure and to the authors' knowledge is not a routine practice. There is limited published literature describing the rehabilitation of those requiring VV ECMO in critical care. 6–8 The aim of this study was to explore the active rehabilitation of those requiring VV ECMO. A retrospective review of the medical records of patients admitted to the Intensive Care Unit at Saint Thomas’ Hospital requiring VV ECMO was undertaken. Owing to the natu...

Sepsis Mortality in Critical Care and Prior Statin Therapy: A Retrospective Cohort Study in Central Argentina.

Sepsis is a major public health problem, frequent, costly, and often fatal. Despite of improvements in supportive treatments the incidence of sepsis and the number of deaths related to sepsis is increasing. Statins have been recently proposed as adjuvants in the treatment of sepsis, but its effects on mortality show conflicting results worldwide. The purpose of this study was to describe the clinical outcome of patients diagnosed with sepsis in a university-affiliated hospital in central Argentina and to evaluate it in relation to a group of septic patients with previous use of statins before the onset of sepsis. The present study was conducted as an observational retrospective research from April 2010 to December 2014 with patients over 18 years of age which were assigned to statins or control groups. Out of 2906 patients, 231 matched study and diagnostic criteria for sepsis and among them 33 (14.3%) belonged to the group of statins. The mean age was 64.2 ± 14.3 years. The severity of sepsis on admission was as follows: Sepsis, n=147 (63.6%), Severe sepsis, n=26 (11.3%) and Septic shock, n=58 (25.1%). The mean length of stay in Intensive Care Unit (ICU) was10.8 ± 9.6 days and 21.2 ± 17 days in general hospital ward settings, without differences between groups of statin users and controls, p=0.873 and p=0.766, respectively. The in-hospital mortality rate was 31.2% (n=72). Previous statin use did not affect in-hospital or 30-day mortality (OR 0.978; 95% CI 0.339 to 2.274; p=0.789). Creatinine levels on days 3 and 14 were substantially higher in statins group (1.80 ±1.39 vs. 1.45 ± 1.47 mg/dl) (p=0.010) and (1.42 ± 1.14 vs. 1.09 ± 1.05 mg/dl) (p=0.009), respectively. Prior use of statins did not reduce in-hospital or 30-day mortality in septic patients and it may be associated with impaired renal function in this group of Argentinian participants.

Fundamentals of aerosol therapy in critical care.

Drug dosing in critically ill patients is challenging due to the altered drug pharmacokinetics–pharmacodynamics associated with systemic therapies. For many drug therapies, there is potential to use the respiratory system as an alternative route for drug delivery. Aerosol drug delivery can provide many advantages over conventional therapy. Given that respiratory diseases are the commonest causes of critical illness, use of aerosol therapy to provide high local drug concentrations with minimal systemic side effects makes this route an attractive option. To date, limited evidence has restricted its wider application. The efficacy of aerosol drug therapy depends on drug-related factors (particle size, molecular weight), device factors, patient-related factors (airway anatomy, inhalation patterns) and mechanical ventilation-related factors (humidification, airway). This review identifies the relevant factors which require attention for optimization of aerosol drug delivery that can achieve better drug concentrations at the target sites and potentially improve clinical outcomes.

Chest Wall Resection and Reconstruction

Since the first accounts of empyema treatment by Hippocrates of Kos, who pioneered surgical procedures of the chest wall and the emergence of thoracic surgery during the late 19th and early 20th century specifically to develop treatment strategies for tuberculosis, chest wall resection and reconstruction has become a mainstay of septic and oncologic thoracic surgery. Thanks to significant improvements in surgical technique, anesthesiological management, critical care therapy, the advent of antibiotics, and a continuously evolving array of grafts suitable for secondary repair, nowadays even extensive full thickness resection can be performed with acceptable overall morbidity and mortality. We present an overview of current indications for chest wall resection and list materials suitable for repair, ranging from synthetic meshes to tissue-engineered grafts.

Descending necrotizing mediastinitis : Treatment concept with focus on thoracic surgery

Descending necrotizing mediastinitis (DNM) originates from odontogenic or oropharyngeal infections which spread along preformed cervicothoracic spaces into the mediastinum and requires emergency multidisciplinary treatment. A total of seven patients were diagnosed with DNM based on typical radiological features in a cervicothoracic computed tomography (CT) scan and subsequently underwent standardized transcervical and open transthoracic radical debridement. The initially detected polymicrobial spectrum of pathogens was dominated by streptococci followed by enterobacteriae. After calculated antibiotic treatment a shift in the spectrum of pathogens was noted and in particular a mycotic superinfection occurred in 43 % of the cases. Anterolateral thoracotomy was performed for radical removal of tissue necrosis and mediastinothoracic drainage extending to the posterior mediastinum was placed. In selected cases, cervico-mediastino-thoracic tubes were transmediastinally placed by the rendevouz technique either in the previsceral or retrovisceral mediastinal space. Despite predominantly advanced mediastinitis (Endo classification type II B) in this patient cohort, the mortality only reached 14 %. Rapid diagnosis, anatomical knowledge, understanding of the progression of infections as well as critical care, antimicrobial treatment and multidisciplinary radical surgical therapy are paramount for successful treatment of DNM. We favor anterolateral thoracotomy as the standard open transthoracic approach to the mediastinum. Placement of cervico-mediastino-thoracic irrigation drains can help to limit DNM.

Extracorporeal Membrane Oxygenation Applications in Cardiac Critical Care.

The use of extracorporeal membrane oxygenation therapy (ECMO) in cardiac critical care has steadily increased over the past decade. Significant improvements in the technology associated with ECMO have propagated this recent resurgence and contributed to improved patient outcomes in the fields of cardiac and transplant (heart and lung) surgery. Specifically, ECMO is being increasingly utilized as a bridge to heart and lung transplantation, as well as to ventricular assist device placement. ECMO is also employed during the administration of cardiopulmonary resuscitation, known as extracorporeal life support. In this review, we examine the recent literature regarding the applications of ECMO and also describe emerging topics involving current ECMO management strategies.

A multicenter study of 30 days complications after deceased donor liver transplantation in the model for end-stage liver disease score era.

Knowledge of risk factors for posttransplant complications is likely to improve patient outcomes. Few large studies of all early postoperative complications after deceased donor liver transplantation (DDLT) exist. Therefore, we conducted a retrospective, cohort study of 30-day complications, their risk factors, and the impact on outcomes after DDLT. Three centers contributed data for 450 DDLTs performed from January 2005 through December 2009. Data included donor, recipient, transplant, and outcome variables. All 30-day postoperative complications were graded by the Clavien-Dindo system. Complications per patient and severe (≥ grade III) complications were primary outcomes. Death within 30 days, complication occurrence, length of stay (LOS), and graft and patient survival were secondary outcomes. Multivariate associations of risk factors with complications and complications with LOS, graft survival, and patient survival were examined. Mean number of complications/patient was 3.3 ± 3.9. At least 1 complication occurred in 79.3%, and severe complications occurred in 62.8% of recipients. Mean LOS was 16.2 ± 22.9 days. Graft and patient survival rates were 84% and 86%, respectively, at 1 year and 74% and 76%, respectively, at 3 years. Hospitalization, critical care, ventilatory support, and renal replacement therapy before transplant and transfusions during transplant were the significant predictors of complications (not the Model for End-Stage Liver Disease score). Both number and severity of complications had a significant impact on LOS and graft and patient survival. Structured reporting of risk-adjusted complications rates after DDLT is likely to improve patient care and transplant center benchmarking. Despite the accomplished reductions in transfusions during DDLT, opportunities exist for further reductions. With increasing transplantation of sicker patients, reduction in complications would require multidisciplinary efforts and institutional commitment. Pretransplant risk characteristics for complications must factor in during payer contracting.