Telemedicine for Kidney Transplant Recipients:Current State, Advantages, and Barriers

Telemedicine is defined as the use of electronic information and communication technologies to provide and support healthcare at a distance. In kidney transplantation, telemedicine is limited but is expected to grow markedly in the coming y. Current experience shows that it is possible to provide transplant care at a distance, with benefits for patients like reduced travel time and costs, better adherence to medication and appointment visits, more self-sufficiency, and more reliable blood pressure values. However, multiple barriers in different areas need to be overcome for successful implementation, such as recipients' preferences, willingness, skills, and digital literacy. Moreover, in many countries, limited digital infrastructure, legislation, local policy, costs, and reimbursement issues could be barriers to the implementation of telemedicine. Finally, telemedicine changes the way transplant professionals provide care, and this transition needs time, training, willingness, and acceptance. This review discusses the current state and benefits of telemedicine in kidney transplantation, with the aforementioned barriers, and provides an overview of future directions on telemedicine in kidney transplantation.</p

Long-Term Kidney and Maternal Outcomes After Pregnancy in Living Kidney Donors

For counseling it is important to know if pregnancy after Living Kidney Donation (LKD) affects long-term outcomes of the mono-kidney and the mother. Therefore, we performed a retrospective multicenter study in women ≤45 years who donated their kidney between 1981 and 2017. Data was collected via questionnaires and medical records. eGFR of women with post-LKD pregnancies were compared to women with pre-LKD pregnancies or nulliparous. eGFR before and after pregnancy were compared in women with post-LKD pregnancies. Pregnancy outcomes post-LKD were compared with pre-LKD pregnancy outcomes. 234 women (499 pregnancies) were included, of which 20 with pre- and post-LKD pregnancies (68) and 26 with only post-LKD pregnancies (59). Multilevel analysis demonstrated that eGFR was not different between women with and without post-LKD pregnancies (p = 0.23). Furthermore, eGFR was not different before and after post-LKD pregnancy (p = 0.13). More hypertensive disorders of pregnancy (HDP) occurred in post-LKD pregnancies (p = 0.002). Adverse fetal outcomes did not differ. We conclude that, despite a higher incidence of HDP, eGFR was not affected by post-LKD pregnancy. In line with previous studies, we found an increased risk for HDP after LKD without affecting fetal outcome. Therefore, a pregnancy wish alone should not be a reason to exclude women for LKD.</p

Comparison of a home-based (multi) systemic intervention to promoting Medication AdheRence and Self-management among kidney transplant recipients with care-as-usual: the MARS randomized controlled trial protocol

BACKGROUND: After kidney transplantation non-adherence and inadequate self-management undermine clinical outcomes and quality of life. Both have been demonstrated to be substantial in all age groups. However, interventions promoting adherence and self-management among kidney transplant recipients that have proven to be effective are scarce. In this study we aim to develop and test an intervention to optimize adherence and self-management. In this article we describe the background and design of the trial entitled 'promoting Medication AdheRence and Self-management among kidney transplant recipients' (MARS-trial)'. METHODS/DESIGN: This is a single-center, parallel arm randomized controlled trial. Nonadherent kidney transplant recipients aged 12 years or older are eligible for inclusion. Patients will be randomly assigned to either the experimental or a control group. The control group will receive care-as-usual. The experimental group will receive care-as-usual plus the MARS-intervention. The MARS-intervention is an outreaching intervention, based on the principles of (multi) systemic therapy which means involving the social network. A standardized intervention protocol is used for consistency but we will tailor the behavior change techniques used to the specific needs and determinants

Evaluating the feasibility of a nurse-led self-management support intervention for kidney transplant recipients: a pilot study

Background: To support effective self-management after kidney transplantation, a holistic nurse-led self-management support intervention was developed using the Intervention Mapping approach. The primary aim was to evaluate the feasibility, acceptability and fidelity of the intervention for kidney transplant recipients and professionals. The secondary aim was to explore preliminary effects on outcomes. Methods: A pilot study was conducted in 2015–2017 to evaluate the intervention. Nurse Practitioners (NP) guided recipients in assessing 14 life areas using the Self-Management Web. Participants were supported in developing selfregulation skills which can be applied to self-management of the illness. Strategies included goal setting, action planning, and promotion of motivation and self-efficacy. Adult recipients from an outpatient clinic of a Dutch University Hospital who underwent their transplant at least 1 month ago, were invited to participate. NPs, nephrologists and recipients were interviewed to assess feasibility, fidelity and implementation experience. Consultations were videoed and analysed to assess fidelity. To assess the preliminary effects, the intervention group completed baseline (T0) and follow-up (T1) questionnaires on self-management behavior, self-efficacy, quality of life and quality of care. A historical control group of kidney transplant recipients completed the same questionnaires at T1. Results: Twenty-seven recipients agreed to participate in the intervention group, of which 24 completed the intervention and 16 completed baseline and follow-up surveys. The control group consisted of 33 recipients. Professionals and recipients appraised the open, holistic focus of the intervention as a welcome addition to standard care and felt that this helped to build a relationship of trust. Recipients also felt they became more competent in problem-solving skills. The within-group analysis showed no significant increase in patients’ self-management skills. The between-groups analysis showed significantly higher medication adherence among the intervention group (P = 0.03; G = 0.81). The within-groups analysis showed a significantly higher perceived quality of care (P = 0.02) in the intervention group. Conclusion: This holistic nurse-led self-management support intervention was found to be feasible and acceptable by professionals and recipients alike. Thi

A nurse-led self-management support intervention (ZENN) for kidney transplant recipients using intervention mapping: Protocol for a mixed-methods feasibility study

Background: Optimal self-management in kidney transplant recipients is essential for patient and graft survival, reducing comorbidity and health care costs while improving the quality of life. However, there are few effective interventions aimed at providing self-management support after kidney transplantation. Objective: This study aims to systematically develop a nurse-led, self-management (support) intervention for kidney transplant recipients. Methods: The Intervention Mapping protocol was used to develop an intervention that incorporates kidney transplant recipients' and nurses' needs, and theories as well as evidence-based methods. The needs of recipients and nurses were assessed by reviewing the literature, conducting focus groups, individual interviews, and observations (step 1). Based on the needs assessment, Self-Regulation Theory, and the "5A's" model, change objectives were formulated (step 2). Evidence-based methods to achieve these objectives were selected and subsequently translated into practical implementation strategies (step 3). Then, program materials and protocols were developed accordingly (step 4). The implementation to test the feasibility and acceptability was scheduled for 2015-2017 (step 5). The last step of Intervention Mapping, evaluation of the intervention, falls outside the scope of this paper (step 6). Results: The intervention was developed to optimize self-management (support) after kidney transplantation and targeted both kidney transplant recipients and nurse practitioners who delivered the intervention. The intervention was clustered into four 15-minute sessions that were combined with regular appointments at the outpatient clinic. Nurses received a training syllabus and were trained in communi

Psychosocial aspects of medication nonadherence after kidney transplantation

markdownabstract__Background:__ Patients have to take immunosuppressive medication after kidney transplantation to prevent rejection of the graft. This thesis investigated patients’ adherence behavior, attitudes and beliefs about the immunosuppressive regime. The research questions were (1) What is the rate of nonadherence among our population of kidney transplant recipients and does this change over time? (2) What are the attitudes, beliefs and goals of kidney transplant recipients towards the medication regime? (3) To what extent are these attitudes, beliefs and goals related to nonadherence? (4) To what extent is nonadherence related to graft survival? __Methods:__ We used different questionnaires and self-reported nonadherence at different time points in young adults (18-25yrs), the elderly (>65 yrs) and in a kidney transplantation cohort of all ages. __Results:__ Three distinct attitude profiles concerning post-transplant health lifestyle were repeatedly found: (i) patients that were afraid of rejection and therefore take their medication, (ii) patients that feel secure and know how they can take good care of this kidney, and (iii) patients who found their appearance important and experience side-effects of the medication. The profiles were not correlated with nonadherence. Patients find themselves capable of taking the medication correct and understand the importance; nevertheless 6 weeks after kidney transplantation 17% were classified as nonadherent, with a significant lower graft survival. The rate of nonadherenc

Immunosuppressive Drugs and Young Adults: A Difficult Combination

markdownabstract#### Background In our center we encounter serious problems with a number young adult (18- 25yrs) renal transplant recipients that are non-compliant to the medication regime. This could well be one of the reasons for the significantly worse unadjusted 10 years kidney graft survival in this patient group compared to that in recipients > 25 years: 47.2% versus 64.0%. This paper focuses on the attitudes and behavior of young adults towards compliance with the immunosuppressive drugs. #### Method We used Q-methodology to identify attitude profiles associated with noncompliant behavior. Adolescent renal transplant recipients (n=25) sorted a set of 37 statements (Q-set) along a continuum of preferences to reveal categories of individuals who shared common viewpoints. The same Q-set was also used as a topic list for an in-depth interview. In this paper, we focus on the interview results of four statements, related to compliance with immunosuppressive drugs. Each interview was fully written down, using the software program Atlas.Ti® for coding and labeling. #### Results Almost half of respondents (40%) think that forgetting medication will not lead to serious consequences. They feel they took so much medication over the years that they had developed a certain reserve immunity against rejection. Others state that they had become indifferent after experiencing that ‘nothing happened’ after forgetting their medication. Most adolescents declare having no problems taking their medication when going out with friends. They do not feel ashamed, but some lose track of time and simply forget taking medication when they are out with friends. Remarkably, 18 of the 25 young adults (72%) admit to not always taking their medication on time. When they sleep late, only 7 of them set the alarm clock in order to take their medication as prescribed. #### Conclusion Using the Q-set statements as interview topics triggered young adults to ventilate their opinion and reveal their medication practice. Confronting statements on cards appeared to be very useful in communicating with adolescents about difficult subjects such as noncompliance. This helps caretakers in the outpatient clinic to explore and discuss reasons for nonadherence to immunosuppressive drugs. Many young adults are not very accurate in taking medication on time, and 40% even think nothing bad will happen when they forget their immunosuppressive drugs. Healthcare professionals should be aware of this grossly underestimated problem