Education Before Kidney Transplantation: What Do Patients Need to Know?

Astellas Pharma Canada Inc.Peer ReviewedCONTEXT: Poor knowledge about immunosuppressive (IS) medications remains a major problem for patients in the posttransplant setting. Therefore, more effective educational strategies in the pretransplant setting are being considered as a possible method to improve knowledge and readiness for the challenges of posttransplant care. However, the most effective/relevant content of a pretransplant educational program is yet to be determined. OBJECTIVE: To identify pretransplant education topics from the posttransplant patient perspective. DESIGN: A focus group meeting was conducted among 7 high-functioning, stable adult kidney transplant recipients recruited from the Saskatchewan Transplant Program. Demographic information including age, gender, occupation, background/ethnicity, and time since transplant were recorded. A moderator, assistant moderator, and research assistant facilitated the 90-minute focus group meeting using a predetermined semistructured interview guide. The session was audio recorded and transcribed verbatim. Nvivo software was used to code the data and identify emerging themes exploring views of participants relating to the educational information required for pretransplant patients. RESULTS: Patients were satisfied with the education they had received. Ideas were classified into the following major themes-patient satisfaction, transplant waitlist, surgery, medications, posttransplant complications, lifestyle and monitoring, knowledge acquisition, illusion of control, and life changes posttransplant. Knowledge gaps were identified in all areas of the transplantation process and were not exclusive to IS medications. CONCLUSION: Misconceptions regarding transplantation were identified by a group of high-functioning, stable adult recipients who were satisfied with their clinical care. Future educational strategies should aim to address the entire transplantation process and not be limited to medications

Video Education and Behavior Contract to Improve Outcomes After Renal Transplantation (VECTOR): A Randomized Controlled Trial

Holly Mansell,1 Nicola Rosaasen,2 Jenny Wichart,3 Patricia West-Thielke,4 David Blackburn,1 Juxin Liu,5 Rahul Mainra,6 Ahmed Shoker,6 Brianna Groot,7 Kevin Wen,8 Anita Wong,9 Bita Bateni,10 Cindy Luo,11 Paraag Trivedi12 1College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, SK, Canada; 2Saskatchewan Transplant Program, Saskatchewan Health Authority, Saskatoon, SK, Canada; 3Department of Pharmacy, Alberta Health Services, Calgary, AB, Canada; 4University of Illinois Health Sciences System, Chicago, IL, USA; 5Department of Mathematics and Statistics, College of Arts and Science, University of Saskatchewan, Saskatoon, SK, Canada; 6Saskatchewan Transplant Program; Department of Medicine, University of Saskatchewan, Saskatoon, SK, Canada; 7Canadian Hub for Applied and Social Research, University of Saskatchewan, Saskatoon, SK, Canada; 8Division of Nephrology and Transplant Immunology, Department of Medicine University of Alberta, Edmonton, AB, Canada; 9Department of Pharmacy, University of Alberta Hospital, Edmonton, AB, Canada; 10St. Paul’s Hospital, and University of British Columbia, Vancouver, BC, Canada; 11Vancouver General Hospital; Faculty of Pharmaceutical Sciences, the University of British Columbia, Vancouver, BC, Canada; 12Transplant Recipient/Patient Advisor, Regina, SK, CanadaCorrespondence: Holly Mansell, College of Pharmacy and Nutrition, Health Sciences Building (E3208), 107 Wiggins Road, Saskatoon, SK, S7N 5E5, Canada, Email [email protected]: Sub-optimal adherence to immunosuppressant medications reduces graft survival for kidney transplant recipients and adherence-enhancing interventions are resource and time intensive. We performed a multi-center randomized controlled trial to investigate the impact of an electronically delivered intervention on adherence. Of 203 adult kidney transplant recipients who received a de novo kidney transplant n = 173 agreed to participate (intent-to-treat population) and were randomized to the intervention (video education plus behavior contract n = 91) or the control (standard education, n = 82). No significant differences were found between the groups for medication adherence measured by the Basel Assessment of Adherence to Immunosuppressive Medications Scale, intrapatient variability in tacrolimus levels, time in therapeutic range for any immunosuppressant, knowledge, self-efficacy, QOL, or hospitalizations. Among a subgroup of 64 participants randomized to the intervention group who completed a post-intervention questionnaire, two-thirds (67%, n = 43) reported watching at least 80% of the videos and 58% (n = 37) completed the electronic goal setting exercise and adherence contract. An autonomous goal setting exercise and electronic behavioural contract added to standard of care did not improve any outcomes. Our findings reiterate that nonadherence in transplantation is a difficult multifactorial problem that simple solutions will not solve. Trial registration number NCT03540121.Keywords: kidney transplant, solid organ transplant, medication adherence, immunosuppressio

Outcomes of cinacalcet withdrawal in Australian dialysis patients

Background: Secondary hyperparathyroidism (SHPT) in chronic kidney disease is associated with cardiovascular and bone pathology. Measures to achieve parathyroid hormone (PTH) target values and control biochemical abnormalities associated with SHPT require complex therapies, and severe SHPT often requires parathyroidectomy or the calcimimetic cinacalcet. In Australia, cinacalcet was publicly funded for dialysis patients from 2009 to 2015 when funding was withdrawn following publication of the EVOLVE study, which resulted in most patients on cinacalcet ceasing therapy. We examined the clinical and biochemical outcomes associated with this change at Australian renal centres. Methods: We conducted a retrospective study of dialysis patients who ceased cinacalcet after August 2015 in 11 Australian units. Clinical outcomes and changes in biochemical parameters were assessed over a 24‐ and 12‐month period respectively from cessation of cinacalcet. Results: 228 patients were included (17.7% of all dialysis patients from the units). Patients were aged 63±15 years with 182 patients on haemodialysis and 46 on peritoneal dialysis. Over 24 months following cessation of cinacalcet, we observed 26 parathyroidectomies, 3 episodes of calciphylaxis, 8 fractures and 50 deaths. Seven patients recommenced cinacalcet, meeting criteria under a special access scheme. Biochemical changes from baseline to 12 months after cessation included increased levels of serum PTH from 54 (IQR 27‐90) pmol/L to 85 (IQR 41‐139) pmol/L (

Hepatic safety of antibiotics used in primary care

Antibiotics used by general practitioners frequently appear in adverse-event reports of drug-induced hepatotoxicity. Most cases are idiosyncratic (the adverse reaction cannot be predicted from the drug's pharmacological profile or from pre-clinical toxicology tests) and occur via an immunological reaction or in response to the presence of hepatotoxic metabolites. With the exception of trovafloxacin and telithromycin (now severely restricted), hepatotoxicity crude incidence remains globally low but variable. Thus, amoxicillin/clavulanate and co-trimoxazole, as well as flucloxacillin, cause hepatotoxic reactions at rates that make them visible in general practice (cases are often isolated, may have a delayed onset, sometimes appear only after cessation of therapy and can produce an array of hepatic lesions that mirror hepatobiliary disease, making causality often difficult to establish). Conversely, hepatotoxic reactions related to macrolides, tetracyclines and fluoroquinolones (in that order, from high to low) are much rarer, and are identifiable only through large-scale studies or worldwide pharmacovigilance reporting. For antibiotics specifically used for tuberculosis, adverse effects range from asymptomatic increases in liver enzymes to acute hepatitis and fulminant hepatic failure. Yet, it is difficult to single out individual drugs, as treatment always entails associations. Patients at risk are mainly those with previous experience of hepatotoxic reaction to antibiotics, the aged or those with impaired hepatic function in the absence of close monitoring, making it important to carefully balance potential risks with expected benefits in primary care. Pharmacogenetic testing using the new genome-wide association studies approach holds promise for better understanding the mechanism(s) underlying hepatotoxicity

Relief of exertional breathlessness following bariatric surgery for severe obesity: Physiological mechanisms

Purpose: Obese adults are two-to-four times more likely to experience physical activity-limiting breathlessness than their normal weight counterparts. Despite the high prevalence of breathlessness in obesity, researchers and healthcare providers have a limited understanding of the physiological mechanisms of breathlessness on exertion in obesity. Therefore, the aim of this study was to advance the understanding of the physiological mechanisms of exertional breathlessness in obesity by examining the effects of extreme weight loss through bariatric surgery for class III obesity (BMI>40 kg/m2) on physiological and breathlessness responses during cardiopulmonary cycle exercise testing. We hypothesized that relief of exertional breathlessness following bariatric surgery would be primarily related to the reduced metabolic and ventilatory requirements of exercise, while changes in static and dynamic respiratory mechanics would be less important.Methods: We compared cardiac, metabolic, ventilatory, breathing pattern, operating lung volume and breathlessness responses to symptom-limited incremental CPET (25-watts/2-min) in 6 obese adults (3 women) aged 43.7±2.8 years (mean±SEM) before (PRE) and 3-months after bariatric surgery (POST). Pulmonary function test and body composition parameters were also compared PRE and POST.Results: Compared with PRE, body mass, BMI, fat mass and lean body mass decreased by an average of 23.8 kg (129.4±6.2 vs.105.6±5.8 kg), 8.7 kg/m2 (47.1±1.6 vs. 38.4±1.6 kg/m2), 18.5 kg (61.6±4.6 vs. 43.1±4.8 kg) and 4.4 kg (62.2±4.1 vs. 57.8±4.6 kg) in POST, respectively (all p<0.05). Peak power output was not significantly different in POST vs. PRE: 154±21 vs. 133±11 watts (p=0.185). With few exceptions, heart rate, the rate of oxygen uptake, the rate of carbon dioxide production and minute ventilation (V̇E) were lower during exercise in POST vs. PRE. The reduced V̇E response to exercise in POST vs. PRE reflected adoption of a relatively slower (less tachypneic) breathing pattern. Inspiratory capacity (IC) decreased by 0.13 L from rest-to-peak exercise in PRE, reflecting dynamic lung hyperinflation. In contrast, IC increased by 0.21 L from rest-to-peak exercise in POST (p=0.034 vs. PRE). Inspiratory reserve volume (expressed as a percentage of forced vital capacity [IRV%FVC]) was lower at any given V̇E during exercise in POST vs. PRE. Clinically-meaningful decreases in intensity ratings of breathlessness were observed during exercise at standardized submaximal power outputs ≥75 watts in POST vs. PRE; for example, by 1.0 and 1.4 Borg 0-10 scale units at 75-watts (p<0.05) and at the highest equivalent power output of 117-watts (p<0.08). However, these differences did not persist when breathlessness was examined in relation to V̇E. Breathlessness-IRV%FVC curves were rightward shifted during exercise in POST vs. PRE, such that breathlessness intensity ratings were lower at any given IRV%FVC during exercise in POST vs. PRE.Conclusion: Relief of exertional breathlessness following extreme weight loss via bariatric surgery for class III obesity could not be explained by improved breathing mechanics but was mechanistically linked to the reduced metabolic and ventilatory requirements of exercise.Objectifs: Les adultes obèses sont deux à quatre fois plus susceptibles de subir de l'essoufflement qui pourrait limiter leur activité physique comparé à des individus de poids normal. La compréhension des mécanismes physiologiques sur cet essoufflement parmi les chercheurs et professionnels de santé demeurent toutefois limitées. Donc, le but de cette étude était de mieux comprendre les mécanismes physiologiques de l'essoufflement chez les individus obèses en examinant les effets de la perte de poids extrême à la suite d'une intervention de chirurgie bariatrique pour l'obésité de classe III (IMC ≥ 40 kg/m2). À cet effet, nous avons évalué les responses physiologiques et l'essoufflement lors d'un test d'exercice cardio-pulmonaire à base de cycloergomètre. Nous postulons que le soulagement de l'essoufflement à l'effort à la suite d'une chirurgie bariatrique serait principalement lié à la réduction des besoins métabolique et ventilatoires durant l'exercice, tandis que les changements de mécanismes respiratoires statique et dynamique seraient moins important. Méthodologie: Nous avons comparé les paramètres cardiaques, métaboliques, le schéma respiratoire, les volumes pulmonaires ainsi que le taux d'essoufflement atteint à la limite symptomatique lors d'un test d'exercice à intensité progressive sur une bicyclette ergométrique (25 watts/2 min) avec 6 adultes obèses (3 femmes) âgés de 43,7±2,8 ans (moyenne ± SEM) avant (PRÉ) et 3 mois après la chirurgie bariatrique (POST). Les tests de fonction pulmonaire et les paramètres de composition corporelle ont également été évalués PRÉ-POST.Résultats: Par rapport au PRÉ, la masse corporelle, l'IMC, la masse grasse et la masse maigre ont diminué en moyenne de 23,8 kg (129,4 ± 6,2 vs 105,6 ± 5,8 kg), 8,7 kg / m2 (47,1 ± 1,6 vs 38,4 ± 1,6 kg / m2), 18,5 kg (61,6 ± 4,6 vs 43,1 ± 4,8 kg) et 4,4 kg (62,2 ± 4,1 vs 57,8 ± 4,6 kg) dans le POST, respectivement (tous p <0,05). La puissance de sortie maximale n'était pas significativement différente entre le POST et PRÉ: 154 ± 21 vs 133 ± 11 watts (p = 0,185). En dehors de quelques exceptions, la fréquence cardiaque, le taux d'absorption d'oxygène, le taux de production de dioxyde de carbone et la ventilation (V̇E) étaient plus faibles pendant l'exercice durant le POST comparativement au PRÉ. La réduction de la réponse V̇E durant l'exercice dans le POST par rapport au PRÉ reflète l'utilisation d'un schéma respiratoire relativement plus lent (moins de tachypnée). Le fait que la capacité inspiratoire (CI) entre les exercices de repos et les exercices de pointe a diminué de 0,13 L révèle une hyperinflation pulmonaire dynamique. En revanche, la CI a augmenté de 0,21 litre lors de l'exercice de repos à l'exercice maximale dans le POST (p = 0,034 vs PRÉ). Le volume de réserve inspiratoire (exprimé en pourcentage de la capacité vitale forcée [% CVF]) était plus faible à toute mesure de V̇E durant l'exercice dans le POST vs PRÉ. Des diminutions cliniquement significatives sur l'intensité de l'essoufflement ont été observées pendant l'exercice à des puissances de sortie sous-maximales normalisées ≥75 watts en POST vs PRÉ; par exemple, par 1,0 et 1,4 unités d'échelle Borg 0-10 à 75 watts (p <0,05) et à la puissance de sortie équivalente la plus élevée de 117 watts (p <0,08). Cependant, ces différences n'ont pas persisté lorsque l'essoufflement a été examiné par rapport à la V̇E. Les courbes associées à l'essoufflement et IRV%CVF ont été décalées vers la droite pendant l'exercice dans POST vs. PRÉ, de telle sorte que les taux d'intensité d'essoufflement étaient plus faibles à tout IRV% de CVF pendant l'exercice du POST comparativement au PRÉ.Conclusion: Le soulagement de l'essoufflement à l'effort après une perte de poids extrême par chirurgie bariatrique pour l'obésité de classe III ne pouvait être expliquer par une amélioration des mécanismes pulmonaires, mais était plutôt lié à une réduction d'exigences métaboliques et ventilatoires durant l'exercice

Individualized Therapy to Prevent Bone Mineral Density Loss after Kidney and Kidney-Pancreas Transplantation

Background and objectives: Most patients who undergo kidney or kidney-pancreas transplantation have renal osteodystrophy, and immediately after transplantation bone mineral density (BMD) commonly falls. Together, these abnormalities predispose to an increased fracture incidence. Bisphosphonate or calcitriol therapy can preserve BMD after transplantation, but although bisphosphonates may be more effective, they pose potential risks for adynamic bone

Possible Doxazosin-Induced Leukopenia

INTRODUCTION Doxazosin is a selective long-acting a1-adrenergic antagonist. It is indicated for the treatment of benign prostatic hyperplasia and stage I and II (mild to moderate) essential hypertension.1 A MEDLINE search revealed no previous reports of leukopenia associated with the use of doxazosin

Optimization of TriboelectricNanogenerator for Small Power Electronics

TriboelectricNanogenerators (TENGs) is a new era energy source to power portable small electronic devices. This paper presents the fabrication of vertical contact separation mode TENGs. Three different TENGs device prototypes are fabricated: (1) Kapton-Aluminium; (2) Teflon-Aluminium and (3) Room Temperature Vulcanizing (RTV)-Aluminium. To optimize the performance of TENGs the effect of various parameters such as thickness of dielectric layer, contact time between two layers and contact separation movement of layers have been observed. Experimental result demonstrates that the output voltage increases initially and then decreases with the increase in thickness of dielectric layer. It is also reported that output voltage of TENGs decreases and increases with the increase in contact time and contact separation movement respectively. In this work, an output voltage obtained from TENGs is suitable to drive applications based on small power electronics.</jats:p