The Kidney Transplant Evaluation Process in the Elderly: Reasons for Being Turned down and Opportunities to Improve Cost-Effectiveness in a Single Center

Background. The kidney transplant evaluation process for older candidates is complex due to the presence of multiple comorbid conditions. Methods. We retrospectively reviewed patients ≥60 years referred to our center for kidney transplantation over a 3-year period. Variables were collected to identify reasons for patients being turned down and to determine the number of unnecessary tests performed. Statistical analysis was performed to estimate the association between clinical predictors and listing status. Results. 345 patients were included in the statistical analysis. 31.6% of patients were turned down: 44% due to coronary artery disease (CAD), peripheral vascular disease (PVD), or both. After adjustment for patient demographics and comorbid conditions, history of CAD, PVD, or both (OR = 1.75, 95% CI (1.20, 2.56), p=0.004), chronic obstructive pulmonary disease (OR = 8.75, 95% CI (2.81, 27.20), p=0.0002), and cancer (OR 2.59, 95% CI (1.18, 5.67), p=0.02) were associated with a higher risk of being turned down. 14.8% of patients underwent unnecessary basic testing and 9.6% underwent unnecessary supplementary testing with the charges over a 3-year period estimated at $304,337. Conclusion. A significant number of older candidates are deemed unacceptable for kidney transplantation with primary reasons cited as CAD and PVD. The overall burden of unnecessary testing is substantial and potentially avoidable

A terminal year end report of HIM

Venture History HIM is a passion project that unites spirituality and style. Initiated by a Young Preacher and a Minimalist Fashionista, HIM was born out of the idea of preaching and living up to His words and ideals through contemporary life-wear. The design aesthetics of every shirt is simple and timeless, just like HIM. With great passion to start a meaningful cause, the owners made HIM a fashionable social enterprise with the advocacy: #WearShareCare. With the proponent’s desire to test whether there is a market for her idea, the author started selling shirts to her friends and coworkers and it turned out well with a successful outreach party for its initial chapter. Venture Description Operating under the apparel industry, which continues to develop positively in the coming years, HIM is on its development/startup stage. Despite several worship/advocacy t-shirt brands present in the fashion industry today, HIM possesses unique features that will make it stand up for its own brand. These are the following: (1) HIM is hand-embroidered; (2) HIM accepts custommade orders; (3) HIM advocates statements in a different aesthetics – minimalist and stylishly subtle; (4) HIM is socially responsible. Venture Organization HIM will operate as a sole-proprietorship. As a startup venture, HIM will be composed of the following management personnel: Chief Executive Officer/Marketing Manager/Sales Representative, Chief Operations Officer/Financial Officer/Sales Representative and Production Manager. The personnel running HIM have extensive experiences in corporate businesses as well as newly established brand. The author and owner, for instance, specifically works as a marketing and sales manager for a Philippine-based global accessory brand and is updated with the current trends in terms of marketing as well as the latest trends in fashion. In addition, the coowner holds the International Coordinator position for an International Dominican Youth Movement and is well exposed to various religious groups and sectors. The management is also connected to a number of people with business and financial background who could serve as advisers for the business. Venture Market Apparel and Footwear industry continues to develop positively despite economic challenges. According to Euromonitor, sales of Philippine apparel sector was valued at Php 377.5 billion in 2017. With this positive plight, HIM aims to target yuppies and Filipinos belonging in the middle class to upper middle. Religious organizations, evangelizers, and small private companies are the secondary target market of HIM. An illustration of the target market\u27s lifestyle may include: a person who is proud of his/her faith, fashionable and has eye for classic staples, visits bazaars and follows the latest trends on social media, confident to purchase online and generous enough to help other people. HIM will be beneficial by offering comfort and style, sharing innovative techniques and advocating social responsibility. Aside from the stylish and comfortable staple product that can be worn a couple of times, HIM will also be agents in advocating positivity and preaching good news while assisting its customers in giving back. 2 The major competitor of HIM would be the other statement shirt brands particularly, Worship Generation. This brand has been well established as it has been one of the pioneers in worship statements and thus, have founded several distribution channels in malls. However, this brand has an entirely different design aesthetics compared to HIM as it is digitally printed with vibrant designs and its price point is higher than HIM’s target retail price. Other competitors would be typical shirt brands with urban and colloquial statements and/or graphics such as Linya-linya, Magnificat, The Perfect White Shirt, and several international and local apparel brands like Bench, Artwork, Penshoppe, H&M, etc. Venture Operations The capital needed for the venture to start is estimated at Php 98,220. For the most part, this will include expenses on inventory for product development, licenses and permit and operational expenses. Marketing expense may take a small percentage in the total start-up capital as the business format would be using more of online marketing strategies and personal connections, which are less costly. Venture Financing Since the startup cost for HIM is relatively feasible, the team would be obtaining funds through personal savings as well as to seeking financial assistance and debt from relatives and co-owners when the need arises

The Scope of Telemedicine in Kidney Transplantation: Access and Outreach Services.

Access to transplant centers is a key barrier for kidney transplant evaluation and follow-up care for both the recipient and donor. Potential kidney transplant recipients and living kidney donors may face geographic, financial, and logistical challenges in engaging with a transplant center and maintaining post-transplant continuity of care. Telemedicine via synchronous video visits has the potential to overcome the access barrier to transplant centers. Transplant centers can start the evaluation process for potential recipients and donors via telemedicine, especially for those who have challenges to come for an in-person visit or when there are restrictions on clinic capacities, such as during a pandemic. Similarly, transplant centers can use telemedicine to sustain post-transplant follow-up care while avoiding the burden of travel and its associated costs. However, expansion to telemedicine-based kidney transplant services is substantially dependent on telemedicine infrastructure, insurer policy, and state regulations. In this review, we discuss the practice of telemedicine in kidney transplantation and its implications for expanding access to kidney transplant services and outreach from pretransplant evaluation to post-transplant follow-up care for the recipient and donor

Current landscape of kidney allocation: Organ procurement organization perspectives

Organ procurement organizations (OPOs) play a central role in the recovery, preservation, and distribution of deceased donor kidneys for transplantation in the United States. We conducted a national survey to gather information on OPO practices and perceived barriers to efficient organ placement in the face of the new circle-based allocation and asked for suggestions to overcome them. Of the 57 OPOs, 44 responded (77%). The majority of OPOs (61%) reported barriers to obtaining a kidney biopsy, including lack of an available pathologist. Most OPOs (55%) indicated barriers to pumping owing to a lack of available staff and transportation. Respondents agreed or strongly agreed that the new allocation system has worsened transportation challenges (85%), increased provisional acceptances of kidneys (66%), increased communication challenges with transplant centers (68%), and worsened the efficiency of organ allocation (83%). OPO-suggested solutions include making transplant centers more accountable for inefficient selection practices, developing reliable transportation options, and removing the requirement for national sharing. These findings underscore the need to examine closely the trade-offs of the new allocation system with respect to costs, organ ischemia, and discard. These findings may help inform practice and policy for overcoming transportation barriers and improving the efficiency of organ placement.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/176272/1/ctr14925-sup-0004-TableS1.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/176272/2/ctr14925_am.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/176272/3/ctr14925.pd

Telemedicine services for living kidney donation: A US survey of multidisciplinary providers.

Individuals considering living kidney donation face geographic, financial, and logistical challenges. Telemedicine can facilitate healthcare access/care coordination. Yet difficulties exist in telemedicine implementation and sustainability. We sought to examine centers practices and providers attitudes toward telemedicine to improve services for donors. We surveyed multidisciplinary providers from 194 active adult US living donor kidney transplant centers; 293 providers from 128 unique centers responded to the survey (center representation rate = 66.0%), reflecting 83.9% of practice by donor volume and 91.5% of US states/territories. Most centers (70.3%) plan to continue using telemedicine beyond the pandemic for donor evaluation/follow-up. Video was mostly used by nephrologists, surgeons, and psychiatrists/psychologists. Telephone and video were mostly used by social workers, while video or telephone was equally used by coordinators. Half of respondent nephrologists and surgeons were willing to accept a remote completion of physical exam; 68.3% of respondent psychiatrists/psychologists and social workers were willing to accept a remote completion of mental status exam. Providers strongly agreed that telemedicine was convenient for donors and would improve the likelihood of completing donor evaluation. However, providers (65.5%) perceived out-of-state licensing as a key policy/regulatory barrier. These findings help inform practice and underscore the instigation of policies to remove barriers using telemedicine to increase living kidney donation

Association between ezetimibe usage and hepatitis C RNA levels in uninfected kidney transplant recipients who received hepatitis C infected kidneys.

Kidney transplantation (KT) from hepatitis C virus infected (HCV+) donors to HCV negative recipients achieve excellent graft function but have relatively higher rates of post-KT co-infections presumably due to prolonged HCV viremia in transmission-and-treat approach. Ezetimibe acts as an antagonist of Niemann-Pick C1-Like 1 receptor required for HCV entry and theoretically can reduce HCV viremia. However, no data is available to examine the role of ezetimibe as a bridge therapy between KT surgery and direct acting antiviral (DAA) initiation. A retrospective cohort study including 70 HCV+ to HCV negative KT recipients from Methodist University Hospital and Vanderbilt University Medical Center was performed to determine the association between ezetimibe usage and HCV viremia. Twenty patients received ezetimibe daily while 50 patients did not. Primary outcome of study was mean HCV RNA level at 1-2 weeks post-KT and before initiation of DAA. Median (IQR) viral load (VL) in log copies/ml was one log lower in ezetimibe group versus non-ezetimibe group (4.1 [3.7-5.3] vs. 5.1 [4.4-5.5], P = .01), and highest VL was also lower in ezetimibe group (4.2 [3.7-5.4] vs. 5.4 [4.7-5.9], P = .006). We concluded that ezetimibe bridge therapy might be associated with reduction in HCV VL while waiting for DAA initiation in HCV+ to HCV negative KT recipients

Medical and Surgical Management of the Failed Pancreas Transplant

Despite the continued improvements in pancreas transplant outcomes in recent decades, a subset of recipients experience graft failure and can experience substantial morbidity and mortality. Here, we summarize what is known about the failed pancreas allograft and what factors are important for consideration of retransplantation. The current definition of pancreas allograft failure and its challenges for the transplant community are explored. The impacts of a failed pancreas allograft are presented, including patient survival and resultant morbidities. The signs, symptoms, and medical and surgical management of a failed pancreas allograft are described, whereas the options and consequences of immunosuppression withdrawal are reviewed. Medical and surgical factors necessary for successful retransplant candidacy are detailed with emphasis on how well-selected patients may achieve excellent retransplant outcomes. To achieve substantial medical mitigation and even pancreas retransplantation, patients with a failed pancreas allograft warrant special attention to their residual renal, cardiovascular, and pulmonary function. Future studies of the failed pancreas allograft will require improved reporting of graft failure from transplant centers and continued investigation from experienced centers