Transplant Team Research Articles

Surviving White-out: How to Manage Severe Noninfectious Acute Lung Allograft Dysfunction of Unknown Etiology.

Surviving White-out: How to Manage Severe Noninfectious Acute Lung Allograft Dysfunction of Unknown Etiology.

Strahlentherapeutische Behandlung von Leukämien

HintergrundLymphoide Zellen weisen eine hohe Strahlensensitivität auf, sodass die Strahlentherapie eine sinnvolle Ergänzung der Systemtherapie bei Leukämien darstellt. Vor allem als konditionierende Behandlung vor allogener Stammzelltransplantation ist die Radiotherapie in Form einer Ganzkörperbestrahlung etabliert.Ziel der ArbeitDie vorliegende Arbeit ermöglicht einen Überblick über Durchführung und Nebenwirkungen der strahlentherapeutischen Behandlung bei Leukämien. Hierbei werden insbesondere die (Langzeit‑)Nebenwirkungen nach Ganzkörperbestrahlung dargestellt.Material und MethodenEs erfolgte eine selektive Literaturrecherche über die Datenbank PubMed zur Radiotherapie von Leukämien und zu Ganzkörperbestrahlungen mit Fokus auf Nebenwirkungen sowie technische und konzeptionelle Neuerungen.ErgebnisseDie Ganzkörperbestrahlung ist eine effektive Therapie zur Konditionierung vor allogener Stammzelltransplantation und weist ein diverses, aber beherrschbares, Toxizitätsspektrum mit endokrinen, kardiopulmonalen, okulären, nephrologischen und neurologischen Langzeitnebenwirkungen sowie Sekundärneoplasien auf. Zusätzlich kann eine Radiotherapie in Niedrigdosis effektiv zur Behandlung myeloider Sarkome (Chlorome) angewendet werden.SchlussfolgerungDie Vielfalt der Nebenwirkungen nach Ganzkörperbestrahlung erfordert eine interdisziplinäre und langfristige Nachsorgebetreuung durch internistische Onkolog*innen/Transplantationsmediziner*innen und Radioonkolog*innen. Technische Entwicklungen der Strahlentherapie können in Zukunft eine selektive Adressierung des Knochenmarks sowie der lymphatischen Organe realisieren. Aktuell sind diese noch nicht in der klinischen Routine etabliert und werden im Rahmen klinischer Studien evaluiert.

Identifying Modifiable System-Level Barriers to Living Donor Kidney Transplantation

Studying existing health systems with variable living donor kidney transplantation (LDKT) performance and understanding factors that drive these differences can inform comprehensive system-level approaches to improve LDKT. We aimed to quantify previously identified barriers and estimate their association with LDKT performance. We conducted a cross-sectional survey of health professionals (HPs). Statements, rated on a Likert scale of "strongly disagree" to "strongly agree", captured themes related to communication; role perception; HP's education, training and comfort; attitudes; referral process; patient; as well as resources and infrastructure. The percentage who agreed with these statements was analyzed and compared by LDKT performance (living donation rates higher or lower than the national average) and participant characteristics. We obtained 353 complete responses. Themes related to poor communication, poor role perception, and HPs education or training or comfort emerged as barriers to LDKT. When compared with HPs from high-performing provinces, those from low-performing provinces had lower odds of agreeing that their province promoted LDKT (adjusted odd ratio [aOR]= 0.27, 95% confidence interval [CI]: 0.16-0.48). They also had lower odds of initiating discussions about LDKT (aOR= 0.30, 95% CI: 0.17-0.55), and higher odds of agreeing that the transplant team is best suited to discuss LDKT (aOR= 2.64, 95% CI: 1.60-4.33) and that more resources would increase LDKT discussions (aOR= 2.06, 95% CI: 1.25-3.40). Nonphysician role and less than 10 years of experience were associated with the level of agreement across several themes. Creating guidelines, streamlining evaluations, and improving communication were ranked as priorities to increase LDKT. There are system-level barriers to LDKT and some were more prevalent in low-performing provinces. Interventions to eliminate them should be implemented in conjunction with patient-level interventions as part of a comprehensive system-level approach to increase LDKT.

P2.06: A Survey of Transplant Recipient Attitudes Regarding Contraception and Pregnancy

Background: While transplant professional society recommendations regarding contraception and pregnancy after solid organ transplantation (SOT) exist, counseling varies and some physicians discourage pregnancy. Patient preferences and attitudes about these issues are largely unknown. Methods: Informed by the literature, we developed a survey instrument that was piloted among SOT recipients and conducted cognitive interviews to ensure item clarity. Items included multiple choice questions regarding contraceptive options and Likert scales about pregnancy concerns (i.e., 1-not at all concerned, to 5- extremely concerned) and attitudes (i.e., 1-does not describe their feelings, to 5-clearly describes their feelings). The survey was administered using Qualtrics in the posttransplant clinics at U Penn and Columbia University. All female SOT recipients aged <50 yrs were eligible. We used descriptive and inferential statistics to characterize participant views. Results: 243 women completed the survey. Mean age was 37.5 yrs (SD 8.1yrs); 46.1% were White, 29.2% were Black and 16.5% were Latino. Most participants had received a kidney transplant (66.7%), but 7% had a kidney-pancreas, 14.4% a liver, 13.2% a heart and 7% a lung transplant; 6.5% were multi-organ recipients. Of the 45.3% who reported currently using contraception, condoms (41.8%), intrauterine devices (26.4%), withdrawal (12.2%) and the combination pill (10%) were most common; side effects and pretransplant use were the main reasons for contraception method selection. Only 42% of participants recalled signing the mycophenolate REMS. Prior pregnancy was common (60.1%), and 38.3% were considering pregnancy in the future. Acute rejection (mean 2.55, SD=2.45) or loss of transplant function (mean 2.58, SD=1.45) were less salient among most respondents compared to other potential pregnancy concerns. While concerns about maternal (mean 2.90, SD=1.42) or fetal (mean 2.93, SD=1.49) complications were moderate overall, they were lowest among liver recipients (mean 2.33, SD=1.31; mean 2.48, SD=1.59, respectively). Generally, respondents did not support the sentiment that transplant recipients should not become pregnant (mean 1.90, SD=1.15) nor that a limited life expectancy was a justification for avoiding pregnancy (mean 1.91, SD=1.09); with liver and kidney recipients were most strongly opposed. Among all participants, strong support was expressed for decisions around pregnancy being made jointly by the patient and the transplant team together (mean 4.17, SD=1.15). Conclusions: Contraceptive use was not universal, and some of the most common methods have high failure rates. Side effects and familiarity drive contraceptive choice. Many SOT recipients are interested in posttransplant pregnancy and wish to make these decisions together with the transplant team. There were differences in views among respondents by transplant type, highlighting the need for individualized conversations.

P8.040: Vascular Surgeon in Transplantation Team, Is There a Room For Such Specialist?

P8.040: Vascular Surgeon in Transplantation Team, Is There a Room For Such Specialist?

33863 Successful use of dupilumab for treatment of atopic dermatitis in a liver transplant patient

There is a paucity of data regarding the use of dupilumab treatment of atopic dermatitis (AD) in solid organ transplant patients. We report a case of successful treatment of AD in an orthotopic liver transplant (LT) patient with dupilumab with favorable clinical response and no observed side effects throughout two years of treatment. A 65-year-old Caucasian female with history of orthotopic LT for cirrhosis 17 year prior, presented to dermatology clinic with 2-year history of a pruritic eruption involving bilateral extremities. Punch biopsy revealed spongiotic dermatitis with eosinophils, consistent with atopic dermatitis, allergic contact dermatitis, or id reaction. Photo-patch testing revealed positivity for methyldibromo glutaronitrile, benzalkonium chloride, and benzophenone. Despite numerous trials of medium- and high-potency topical steroids as well as intramuscular and oral corticosteroids, the patient experienced continued pruritus and repeated flares. Phototherapy and immunosuppressives including methotrexate and cyclosporine were contraindicated due to the patient’s photo-allergy and LT status on a stable dose of tacrolimus, respectively. After extensive discussion with the patient’s primary care and transplant teams, the decision was made to begin dupilumab. After 1 month of treatment, the patient experienced near clearance of rash, minimal flares that were easily controlled with adjunct topical corticosteroids, and a 90% improvement in subjective pruritus, with no adverse effects. This response was sustained throughout an additional 2 years of treatment. We report this case of successful dupilumab treatment of AD in a LT patient to raise awareness to the safety and efficacy of its use in this patient population.

P11.08: International Registry in Organ Donation and Transplantation (IRODAT) – 2021 Worldwide Data

Introduction: IRODaT is the first registry in this field, which contains statistics of deceased/living donors and transplants. Out of the 111 countries with organ donation or transplantation (D&T) activity, 86 national reporters have submitted data to IRODaT during the last 19 years. Methods: Each participant country inserts their own data to the website and all data are validated. The information registered follows the definition of “The Critical Pathway of Deceased Donation (1)”, ensuring uniformity throughout the registry and aiding correct interpretation of the data by the scientific community. The data could be verified contacting the official reporter when it is needed. The compilation of all this information worldwide can be accessed by the whole community. Results: Currently twenty one countries have summited the database from 2021 at the IRODaT registry. Although organ D&T rates mostly dropped as expected due to the emergency of COVID-19 worldwide, some countries had the highest improvement in deceased donation (DD) compared to 2020 data, such as: Spain (from 37,97 to 40,2 pmp), USA (from 38,03 to 41,88 pmp), Italy (from 21,6 to 22,52 pmp); Czech Republic (from 23,3 to 25,06 pmp), Argentina (from 9,82 to 13,13 pmp) and Iceland (from 13,33 to 29,35 pmp); while Australia, Austria, Denmark and Estonia reported a downward trend with16 from 18 pmp; 20,26 from 23,9 pmp;16,90 from 21,38 pmp and 15,79 from 24,83 pmp and respectively. The increase in the DD activity of Saudi Arabia and United Arab Emirates is significant by 150% and 400% compared to the previous year. Regarding Brazil and Portugal preliminary data, the numbers collected included only the first semester of 2021 and are excluded in the figure 1. Six countries have reported an increase in Donation After Cardiac Death (DCD type III) including Spain, the US and Italy, in which DCD donation represents more than 30% of their total number of deceased donations. Thus far, thirteen countries have reported living donation activity (LD) led by Saudi Arabia (37,4 ppm), the US (19,75 ppm) and Cyprus (11,59 ppm). The number of LD performed was affected significantly since many programs were deferred. Conclusions: In 2021, the challenges hospitals faced, including restrictions, flight reductions and border closures affected national programs worldwide as reflected above. Nevertheless, coordination and transplant teams have minimized the impacts of the pandemic and while health resources were globally disproportionally affected, certain countries managed to increased D&T rates.

Risk Factors for Urologic Complications After Kidney Transplantation and Impact in Graft Survival.

Background and PurposeKidney transplantation (KT) is the best therapy for chronic kidney disease (CKD). Major urologic complications (MUCs) are the second etiology associated to morbidity and graft loss following KT, after rejection episodes. The objective of this study was to estimate the incidence, risk factors and impact on graft survival associated to urological complications in KT patients.Patients and MethodsA retrospective cohort based on electronic patient files of kidney transplant recipients from Colombiana de Trasplantes was created for the period August 2008 to September 2019. Initiation of follow-up was defined as the date of transplantation up to 3 years post-transplantation. Incidence of ureteral stenosis, ureteral obstruction, and ureteral leak was measured. A logistic regression multivariate model was adjusted to determine the associated factors to MUCs (yes/no). Patient and graft survival time were analyzed using a Kaplan-Meier method.ResultsA total of 1584 KT patients were included in the cohort. MUCs were present in 195 (12.6%) KT patients. We found that dialysis duration (OR: 1.004; p = 0.02) remained significant for the incidence of MUCs in KT patients of deceased donors. Probability of graft and patient survival at 3 years of follow-up was 90.5% and 85.5%, respectively. No significant difference was found on graft and patient survival in KT patients with or without MUCs.ConclusionMUCs are frequent complications for KT. We did not observe significant differences in graft or patient survival according to the presence of MUCs. The identification of MUCs and risk factors may guide transplant teams for future surgical and clinical decisions.

P5.05: Development of a Multidisciplinary Protocol for Thoracic Organ Donation Process

Introduction: In Brazil, transplants of solid thoracic organs are less frequent than those of solid organs (kidney and liver, for example). With the increase in survival and the quality of life of transplant patients, the indication for transplants and the demand for this therapy have grown significantly in the last two decades. However, although the demand and effectiveness of transplants has increased, the lack of organs remains one of the greatest barriers for transplant teams in all countries, as the demand is increasing in relation to the realization of donations, thus increasing the lists waiting. Even with the existence of some protocols for the maintenance of the potential donor, we can observe that the use of organs for transplantation remains reduced in Brazil. Objectives: To develop a systematic multidisciplinary protocol aimed at the process of donating thoracic organs to the Intra-Hospital Transplant Commission, based on a bibliographic survey of a synthesis of evidence in the specialized scientific literature to assist in the construction of the care protocol. Methods: Systematic review of the specialized literature to develop a systematic protocol of specific care for chest uptake; construction of a questionnaire based on the scientific evidence researched in the specialized literature, and subsequent technical review of such evidence, carried out by a committee of experts. Results: Following the selection criteria available in the systematic literature review, twelve (12) studies for the extraction of scientific evidence were listed, all available in English. In all, twenty-one (21) scientific evidences were collected from their total sum. The expert committee was composed of seventeen (17) members, who had access to the questionnaire. The categorization of respondent subjects was as follows: nine (9) doctors, seven (7) nurses and one (1) physiotherapist. The set of evidence shown here can contribute to improving the outcome, in providing reliable scientific information and in a broader field of engagement of the multidisciplinary team in this process. Three (3) domains were designed, and from these the protocol presented here was built. Conclusion: The study developed the domains of the thoracic organ donation process, and proposed actions that can be carried out by the multidisciplinary health team in the various scenarios existing in Brazilian cities. The review used as a scientific basis systematized new scientific evidence for the academic and/ or care community. Finally, this Multidisciplinary Protocol for the Process of Donating Thoracic Organs is the beginning of a trail of knowledge that aims to reduce waiting time and bring more quality of life to the 277 heart transplant candidates and the 195 lung transplant candidates who exist in the country in 2021. Keywords: organ donation; evidence-based practice; systematic review.

P10.01: How Did the War Affect Organ Transplantation in Syria?

Since 2011, the Syrian conflict has destroyed much of the country’s infrastructure. The deteriorating humanitarian situation has involved health workers and facilities. In 2010, before the war, 385 kidney transplants were performed in Syria. This number declined to 154 in 2013 (60% less) before increasing to 251 transplants in 2018, which is still 35% less than the number of transplants performed before the war. In addition, the number of operational kidney transplant centers has decreased from 8 in 2010, distributed over 3 cities, to only 4 in 2013, all located in Damascus, which increased to 6 centers in 2019. Interestingly, with regard to type of living donor, the percentage of unrelated kidney donors has decreased by 20% for unclear reasons. Another alarming statistic is that more than 50% of kidney transplant physicians and surgeons are no longer practicing transplant medicine in their centers, either because they have left the country or because their centers had become nonoperational. Since the war, free and timely provision of immunosuppressive drugs for all patients in all provinces has been a leading challenge for health authorities and transplant patients. This difficulty has led to adverse medical consequences for patients. A project to initiate liver transplant came to a halt because of complex reasons but mainly because foreign trainers could not visit Syria. Although the autologous bone marrow transplant program had slowed until recently, it has become more active, involving both autologous and allogeneic transplants. The deceased-donor program is still not available in Syria; the war has just reinforced the many reasons that prevented the start of this program before the conflict. The commitment of transplant teams despite these large challenges continues to be extraordinary. The Syrian conflict has affected all aspects of organ transplant, paralyzing new projects and negatively affecting existing programs.

337.6: Ultrasound Scanning in Lung Procurement. Protocol For Decision-Making With the Purpose of Increasing Transplant Eligible Lungs

Introduction: Despite having a similar population, Latin America performs 11x less lung transplant procedure than Europe. Improving brain death diagnosis and converting potential donors into real donors is key to improve these numbers. Ultrasonography (US) is common practice in Intensive Care Units. Available literature on its use in the management of brain death donors and lung procurement is extremely scarce. The selection and rejection of lungs for transplantation is usually done with chest X-rays, however US has shown better sensitivity and specificity for the diagnosis of pulmonary pathologies. Lung US allows to identify the reversible causes low PaO2/FiO2 ratio (PaFi), thus allowing to establish specific interventions which, if proved successful, could turn lungs into transplant-eligible lungs. Methods: Introducing a simple Protocol aiming at identifying and treating the main reversible causes of a low PaFi. Respiratory causes of a low PaFi ratio can be either parenchymal or pleural. Parenchymal causes: Pulmonary edema (either neurogenic or cardiogenic) determines the visualization of bilateral and symmetrical B lines. Fluid restriction prioritizing inotropic drugs to revert hypotension and usage of hypertonic solutions can reduce edema. Atelectasis, contusion and pneumonia can appear as patterns for unilateral B lines and/or consolidations. The presence of a static or dynamic air bronchogram can differentiate them. In atelectasis, fiberoptic bronchoscopy can revert the situation. In all other cases, a single lung transplant can be considered, which is a valid option in aged recipients when donors are scarce. Pneumothorax and pleural effusion are both pleural causes of a low PaFi. They can be easily diagnosed through an ultrasound scan, not there being a reason for rejection. Its resolution can turn these lungs into transplant eligible lungs. The pneumothorax —frequently anterior in ventilated patients in dorsal decubitus— may be overlooked in the chest x-ray. Diagnosis is made by the absence of pleural sliding and presence of a lung pint. Pleural effusion is anechoic, present quad sign and the sinusoid sign. The acquisition of skills to diagnose all these conditions does not require much reading and has a fast-learning curve (25 cases monitored). Results: This Protocol is currently used for donor decision-making and will be implemented prospectively by the lung transplant team to assess its ability to increase the number of lungs suitable for transplantation. Conclusions: US is a useful technique to identify reversible and treatable causes of a low PaFi, helping decision-making to increase the number of transplant eligible lungs.

Should Psychotic Experience Contraindicate Organ Transplant? A Narrative Review

The scarcity of organs for transplant and significant rates of organ transplantation failure mean it is important to identify factors relating to transplant success and failure. Experiencing psychosis or mania is often seen as a contraindication for transplant, and many transplant teams have been cautious at transplanting people with significant mental health difficulties. In this paper we explore whether there is any evidence to support this attitude towards psychiatric diagnosis and transplantation; consider modifiable risks to transplantation; and ask what is needed to provide equitable care for individuals with experience of psychosis. To place context to our discussion, we present the experience of a person who had a history of psychotic experience and who was assessed for double lung transplant.

Coronary stent-graft use to salvage a juxta-anastomotic arterial rupture complicating a case of radio-cephalic fistuloplasty

BackgroundStenosis is a common complication of haemodialysis arteriovenous accesses. Endovascular approaches with percutaneous transluminal fistuloplasty have largely replaced open surgical approaches as first line treatment. Vessel rupture is an uncommon complication of fistuloplasty and most reports describe venous rupture. Stent-graft deployment can salvage this, however, its use requires careful assessment of the distal vasculature. Arterial rupture with fistuloplasty has rarely been described in the literature. This is a novel case describing the use of a BeGraft coronary stent-graft to manage juxta-anastomotic arterial rupture and pseudoaneurysm complicating fistuloplasty.Case presentationA 77 year old female with end stage renal failure secondary to systemic amyloid light chain type amyloidosis was referred for a suspected radio-cephalic arteriovenous fistula stenosis after difficulty cannulating with poor flow during dialysis and clinical reduction in the fistula thrill. Both Doppler ultrasound and intravenous fistulography confirmed a venous stenosis 2 cm distal to the anastomosis. The stenosis was treated by fistuloplasty, however, this was complicated by a rupture of the juxta-anastomotic arterial segment intraoperatively. Intermittent balloon tamponade was used to minimise extravasation although a pseudoaneurysm formed within the damaged arterial segment. The patient’s distal neurovascular status was assessed using the Barbeau test and we sonographically confirmed adequate retrograde arterial flow via a complete palmar arch directing blood from the ulnar artery. After discussion with the renal transplant team, a 4 mm BeGraft coronary stent-graft was deployed to control haemorrhage and bypass the pseudoaneurysm until adequate haemostasis and fistula flow was achieved. Follow-up 3 months post-procedure reported the patient continued with haemodialysis using the stented fistula with no further complications.ConclusionsTo our knowledge, this is the first case report describing the application of BeGraft coronary stent-grafts to salvage fistuloplasty of a radio-cephalic arteriovenous fistula stenosis complicated by juxta-anastomotic arterial rupture and pseudoaneurysm formation. We demonstrate the safety and short-term efficacy of this technology.

Technical Aspects of Lung Transplantation: Pediatric and Lobar Transplantation.

Fewer patients undergo pediatric lung transplantation (PLT) than adult lung transplantation. Size mismatch is the key factor that limits the availability of potential donors. Every candidate for PLT is in a different scenario in terms of age, height and weight, size of structures, indications for PLT, the concomitant presence of a cardiac anomaly, and other individual-specific factors; thus, a thorough understanding of pediatric patients’ medical problems is essential. Living-donor lobar lung transplantation (LDLLT) has only been performed once in Korea to date. However, since each step in the LDLLT is a well-established procedure, including intrapericardial lobectomy, lung procurement, and lobar lung transplantation, qualified surgeons and lung transplantation teams are competent to perform LDLLT in clinically necessary situations.

Renal Transplantation in Pure Autonomic Failure.

Renal Transplantation in Pure Autonomic Failure.

The mediating effect of social functioning on the relationship between social support and fatigue in middle-aged and young recipients with liver transplant in China.

ObjectiveThe objective of the study was to explore the relationship between social support and fatigue as well as the mediating role of social functioning on that relationship.BackgroundPsychosocial factors such as social support and social functioning may influence patients’ fatigue symptoms. There is limited evidence on the relationship between social support, social functioning, and fatigue in liver transplant recipients.MethodsA total of 210 patients with liver transplants from two tertiary hospitals were enrolled in the current study. Questionnaires used include one for general demographic data, the Perceived Social Support Scale (PSSS), Social Disability Screening Schedule (SDSS), and Fatigue Symptom Inventory (FSI).ResultsA total of 126 (60%) recipients reported fatigue. Gender, residence, BMI, and liver function were the primary factors affecting fatigue. Social support was positively correlated with social functioning and was negatively correlated with fatigue. The effect of social support on fatigue was partially mediated by social functioning (35.74%).ConclusionThe fatigue of liver transplant recipients should be attended to. The higher the social support, the lower the fatigue of liver transplant recipients. Social support may also reduce fatigue through social functioning. The liver transplant team should help the liver transplant recipient establish a social support system, restore social functioning, and reduce fatigue symptoms.

Consensus recommendations for use of maintenance immunosuppression in solid organ transplantation: Endorsed by the American College of Clinical Pharmacy, American Society of Transplantation, and the International Society for Heart and Lung Transplantation

Advances in maintenance immunosuppression over the past three decades have improved solid organ transplantation outcomes dramatically. Uninterrupted access to immunosuppression is paramount to minimize rejection and maintain allograft and patient survival. There is no standardized approach to maintenance immunosuppression management. Agents used vary based on transplanted organ, center-specific protocol, provider expertise, insurance formularies, ability to cover co-pays, recipient characteristics and tolerability. Published data reflects this heterogeneity. Despite this limitation, maintenance immunosuppression usage cross pollinates between organ groups with standard of care agents often being used off-label, making medication access a challenge for many transplant recipients. A multidisciplinary panel of American transplant clinicians was formed to review published literature on maintenance immunosuppression with the goal to formulate consensus recommendations for their use in specific organ groups. These consensus recommendations are intended to provide transplant clinicians with a summary of literature on maintenance immunosuppression in the modern era and to support transplant team members working to secure medication access for patients.

Consensus recommendations for use of maintenance immunosuppression in solid organ transplantation: Endorsed by the American College of Clinical Pharmacy, American Society of Transplantation, and International Society for Heart and Lung Transplantation: An executive summary.

Advances in maintenance immunosuppression over the past three decades have improved solid organ transplantation outcomes dramatically. Uninterrupted access to immunosuppression is paramount to minimize rejection and maintain allograft and patient survival. Agents used vary based on transplanted organ, center-specific protocol, provider expertise, insurance formularies, ability to cover co-pays, recipient characteristics and tolerability. Published data reflects this heterogeneity. Despite these obstacles, the information about maintenance immunosuppression use cross pollinates between organ groups with standard of care agents often being used off-label, making medication access a challenge for many transplant recipients. A multidisciplinary panel of American transplant clinicians was formed to review published literature on maintenance immunosuppression with the goal to formulate consensus recommendations for their use in specific organ groups. These consensus recommendations are intended to provide transplant clinicians with a summary of literature on maintenance immunosuppression in the modern era, and to support transplant team members working to secure medication access for patients.

Crisis management checklist: lessons learned from the SARS-CoV-2 pandemic.

“Everyone has a plan until they get punched in the mouth.” Never has this quote, uttered in response to a challenger’s reported plan to take the title away from heavyweight champion Mike Tyson, rang truer than in the past 20 months as the global population wrestles with the fallout on the SARS-CoV-2 pandemic. While countless lives were disrupted both directly and indirectly during this time, members of the medical community bore the brunt of this fallout in their personal lives while being asked to perform above capacity in their professional lives simultaneously. Compounding this experience was the fact that injuries, illness, and death from other causes did not halt leaving many in the medical community, and community at large, to face personal tragedies in addition to the pandemic. Our goal is to create a series of discussions using the perspective of our surgical department that faced not only the fallout of the pandemic, but also the unexpected death of an influential mentor/physician and close family member to the department. Unfortunately, this pandemic is not the only time tragedy has struck a surgical department. For example, Louisiana State University and Hurricane Katrina in 2007, and a plane crash killing members of the University of Michigan transplant team. However, the pandemic is certainly the most globally widespread, relevant and recent. We leverage crisis-management strategies from other fields, responses from an internal survey, and thoughts from our surgical team on what worked during these crises, what did not, and how we can begin to create a strategic response for those unexpected moments where you get “punched in the mouth.”

Medication Barriers and Adherence: Experiences of Pediatric Transplant Recipients.

This study examined associations between scores on the Adolescent Medication Barriers Scale (AMBS) and the Parent Medication Barriers Scale (PMBS), patient and family factors, and medication adherence outcomes. Patients and caregivers from a pediatric solid organ transplantation (SOT) program were recruited for participation. Pediatric SOT recipients ages 10 to 21 years were eligible for participation. Analyses included reliability analyses and regression modeling with posttransplant medication adherence measured by Medication Level Variability Index scores. Seventy-three patients and caregivers completed an AMBS or PMBS questionnaire. Patient-caregiver inter-rater reliability was poor to fair. Greater medication barriers were reported among younger and female patients and families with more children. AMBS scores predicted greater nonadherence, while the PMBS was not predictive of adherence. Results point to the difficulty of assessing barriers to medication adherence and the lack of agreement between adolescent patients and caregivers. AMBS scores were more closely aligned with medication nonadherence, whereas PMBS scores may have been more influenced by family social factors. Adolescent reports of medication barriers may offer multidisciplinary transplant teams greater clinical utility when addressing these challenges with patients. Transplant social workers and psychologists should engage adolescents and caregivers in efforts to address medication nonadherence.