Clinical and Socioeconomic Aspects of Kidney Transplantation

For patients that require renal replacement therapy, kidney transplantation is the best option in terms of outcomes and quality of life. However, not all patients have equal access to transplantation, as for various reasons some are not even referred for transplantation. Though not always obvious, a spectrum of reasons may be responsible for non-referral, e.g. insufficient condition to undergo surgery or inadequate mastering of the language to understand and communicate the transplantation process. Other patients are highly sensitized which complicates finding a match. Once transplanted, graft survival may be hampered by various factors causing a fall back on less favorable options for renal replacement therapy. The aims of this thesis were to investigate what factors influence access to living or deceased donor kidney transplantation and what factors influence graft and patient survival once transplantation is carried out. The retrospective cohort studies described in this thesis showed that older patients and patients with unfavorable socioeconomic factors have a decreased chance to receive a living donor kidney transplant. Moreover, age has a negative influence on the chance to receive a deceased donor kidney transplant. Only half of the patients above 55 years that are dependent on the waiting list for deceased donor kidney transplantation will be transplanted. Graft and patient survival were studied using multivariable analyses. While various clinical factors were found to influence graft and patient survival, socioeconomic factors did not influence survival. The combined influence of donor age and donor type showed that the results of living donor kidney transplantation are better than the results of living donor kidney transplantation, independent of donor age. This applied to the number of HLA mismatches between recipient and donor as well. To study the influence of comorbidities on survival a new comorbidity score was developed, the Rotterdam Comorbidity in Kidney Transplantation (RoCKeT) score. Though a higher comorbidity score did influence patient survival, patient survival after transplantation was still remarkably good. The main conclusion is that survival after living donor kidney transplantation is superior to deceased donor kidney transplantation. Living donor kidney transplantation should be accessible for all patients, also for elderly patients with extensive comorbidity and for patients with unfavorable socioeconomic factors. They should be referred for transplantation as early as possible to prevent dialysis, even when they present without a potential living donor. As home based education was added to our standard care for these patients, their chance to become transplanted increases

Living Donor Kidney Transplantation Should Be Promoted among "elderly" Patients

Background. Age criteria for kidney transplantation have been liberalized over the years resulting in more waitlisted elderly patients. What are the prospects of elderly patients on the waiting list? Methods. Between 2000 and 2013, 2622 patients had been waitlisted. Waiting time was defined as the period between dialysis onset and being delisted. Patients were categorized according to age upon listing: 64 years. Furthermore, the influence of ABO blood type and panel reactive antibodies on outflow patterns was studied. Results. At the end of observation (November 2017), 1957 (75%) patients had been transplanted, 333 (13%) had been delisted without a transplantation, 271 (10%) had died, and 61 (2%) were still waiting. When comparing the age categories, outflow patterns were completely different. The percentage of patients transplanted decreased with increasing age, while the percentage of patients that had been delisted or had died increased with increasing age, especially in the population without living donor. Within 6 years, 93% of the population 55 years, 39% received a living donor kidney, while >50% of patients without a living donor had been delisted/died. Multivariable analysis showed that the influence of age, ABO blood type, and panel reactive antibodies on outflow patterns was significant, but the magnitude of the influence of the latter 2 was only modest compared with that of age. Conclusions. "Elderly" (not only >64 y but even 55-64 y) received a living donor kidney transplantation less often. Moreover, they cannot bear the waiting time for a deceased donor kidney, resulting in delisting without a transplant in more than half the population of patients without a living donor. Promoting living donor kidney transplantation is the only modification that improves transplantation and decreases delisting/death on the waiting list in this population

Codon choice in genes depends on flanking sequence information—implications for theoretical reverse translation

Algorithms for theoretical reverse translation have direct applications in degenerate PCR. The conventional practice is to create several degenerate primers each of which variably encode the peptide region of interest. In the current work, for each codon we have analyzed the flanking residues in proteins and determined their influence on codon choice. From this, we created a method for theoretical reverse translation that includes information from flanking residues of the protein in question. Our method, named the neighbor correlation method (NCM) and its enhancement, the consensus-NCM (c-NCM) performed significantly better than the conventional codon-usage statistic method (CSM). Using the methods NCM and c-NCM, we were able to increase the average sequence identity from 77% up to 81%. Furthermore, we revealed a significant increase in coverage, at 80% identity, from < 20% (CSM) to > 75% (c-NCM). The algorithms, their applications and implications are discussed herein

Transition to Practice Programs in Nursing: A Rapid Review

Background Transition to practice can be exceedingly stressful for newly qualified nurses as they grapple with the “reality shock” of everyday practice as an RN. Transition to practice programs were implemented as a support strategy to ease the transition from student to RN and are designed to increase graduates' confidence and competence, improve their professional adjustment, and increase their retention. Method This rapid review was framed by the Cochrane Methods Rapid Review, supported by the PRISMA statement checklist, aiming to identify and describe the benefits of transition to practice programs for newly graduated RNs and their impact on workforce retention. Results The literature revealed that mixed evidence exists regarding the value and benefits of graduate nurse transition programs to both the graduate and the health service. Conclusion There are multiple inconsistencies across clinical settings, organizations, and preceptor-ship/mentoring training, among others, particularly in relation to duration of the program and the amount of formalized contact/study days

The role of goal cognitions, illness perceptions and treatment beliefs in self-reported adherence after kidney transplantation: A cohort study

Objective: Nonadherence to immunosuppressive medication (IM) after kidney transplantation is related to poorer patient and graft outcomes; therefore research into modifiable factors associated with nonadherence is a priority. In this prospective cohort study we investigated whether changes in goal cognitions, illness perceptions, and treatment beliefs were related to self-reported medication adherence six months after kidney transplantation. Methods: Interviews were conducted with patients in the out-patient clinic six weeks (T1: n = 113) and six months (12: n = 106) after transplantation. Self-reported adherence was measured using the Basel Assessment of Adherence to Immunosuppressive Medications Scale (BAASIS (c) Interview). The Brief Illness Perceptions Questionnaire, Beliefs about Medicines Questionnaire and questions on goal cognitions were also administered at both time points. Results: Self-reported nonadherence increased significantly between 6 weeks and 6 months after transplantation from 17% to 27%. Importance of medication adherence as a personal goal and self-efficacy to successfully carry out this goal decreased significantly over time. Perceived necessity of immunosuppressive medication was high but significantly decreased over time. Concerns about the medicines were low. There were no significant changes in illness perceptions or concerns overtime. An increase Conclusion: The self-reported nonadherence levels found in this study so soon after transplantation demonstrate the need for early and continued intervention after kidney transplantation in order to maximise adherence and consequently clinical outcomes. Changes in (unrealistic) beliefs regarding the longevity of the graft may offer a potential target for intervention among nonadherent patients. (C) 2013 Elsevier Inc All rights reserved