Harnessing the patient's "voice" to inform care via qualitative research methods: an important goal, not easily achieved. See the article by Tang et al. on page 3369.
Live donor kidney transplantation is the best treatment option for most patients with late-stage chronic kidney disease; however, the rate of living kidney donation has declined in the United States. A consensus conference was held June 5–6, 2014 to identify best practices and knowledge gaps pertaining to live donor kidney transplantation and living kidney donation. Transplant professionals, patients, and other key stakeholders discussed processes for educating transplant candidates and potential living donors about living kidney donation; efficiencies in the living donor evaluation process; disparities in living donation; and financial and systemic barriers to living donation. We summarize the consensus recommendations for best practices in these educational and clinical domains, future research priorities, and possible public policy initiatives to remove barriers to living kidney donation. Live donor kidney transplantation is the best treatment option for most patients with late-stage chronic kidney disease; however, the rate of living kidney donation has declined in the United States. A consensus conference was held June 5–6, 2014 to identify best practices and knowledge gaps pertaining to live donor kidney transplantation and living kidney donation. Transplant professionals, patients, and other key stakeholders discussed processes for educating transplant candidates and potential living donors about living kidney donation; efficiencies in the living donor evaluation process; disparities in living donation; and financial and systemic barriers to living donation. We summarize the consensus recommendations for best practices in these educational and clinical domains, future research priorities, and possible public policy initiatives to remove barriers to living kidney donation.
Publications on living donor liver transplant have focused on the medical aspects of donor selection, postoperative management, surgical procedures, and outcomes, but little attention has been given to the nursing implications for care of live liver donors during their inpatient stay. Donor advocates from various disciplines are involved during the initial education and evaluation, but most care after surgery is delivered by an inpatient medical team and bedside nursing staff who are not as familiar with the donor and concepts related to donor advocacy. In an effort to improve the overall donor experience and provide safe, high-quality care to patients undergoing elective partial hepatectomy, our academic medical center began a quality improvement project focused on improving the inpatient stay. Inpatient nursing standards and policies and procedures were developed to ensure that consistent care is delivered. However, the infrequency of living donor liver transplantation makes it nearly impossible to have all transplant program staff on a nursing unit be "experts" on donor care. Therefore, our center determined that, similar to the Independent Donor Advocacy Team, a transplant program needs live donor champions on the nursing unit to mirror the goals of the team. To that end, we developed the concept of the Designated Donor Nurse to care for and advocate for live liver donors during the inpatient stay and also to serve as a resource to their colleagues.
Liver transplantation is an acceptable treatment modality for complications of end-stage liver disease from chronic and acute liver failure. In the United States, 16 377 people are currently awaiting liver transplant but only 6492 transplantations were performed in 2007. All options for liver transplantation including Model for End stage Liver Disease allocated, expanded criteria deceased donors, and live donor liver transplantation should be discussed with potential recipients on the waitlist to create an early access plan for safe and expeditious transplantation. After transplantation, careful management to avoid complications and intervene early is necessary. Common postoperative complications include graft dysfunction, vascular thrombosis, biliary tract complications, infection, rejection, neurologic injury, electrolyte imbalances, and drug interactions. A multidisciplinary approach to care including the critical care nurse is necessary for successful long-term outcomes.
Background: One third of live kidney donors have long-term post-donation estimated glomerular filtration rate (eGFR) corresponding to Chronic Kidney Disease (CKD) stage 3. While their risk of CKD progression is low compared to other populations for the same eGFR, they require specific counseling, stricter monitoring and risk factor modification to avert CKD progression. Aim: To study pre-operative predictors for a 1-year post-donation eGFR falling within CKD stage 3 criteria. Methods: Retrospective review of 102 kidney donors between July 2010-July 2012 with complete 1 year follow up data. Baseline and 1-yr eGFR calculated with CKD-EPI equation. Renal volumes (RV) and eGFR adjusted to body surface area (BSA). Predictors of 1-yr eGFR<60 ml/min/1.73m2 assessed by multiple and logistic regression.Table: No Caption available.Results: Significantly associated independent predictors of 1-yr eGFR<60 were: Baseline eGFR (p=0.032) OR 3.624 [CL 1.11-1175] and donor age (p=0.002) OR 3.082 [CL 1.49-6.37] and their interaction (p=0.0051); Preserved RV (p=0.005), OR 2.362 [95% CL 1.29-4.32] for each decrease in 10 cc/BSA*1.73m2 in cohort range 108-225; Borderline BP pre-donation (p=0.020), OR 10.070 [95% CL 1.43-70.74]. Race, gender, metabolic Sme, BSA and BMI were not associated.Figure: No Caption available.Conclusion: In our study, risk of 1-yr eGFR <60 ml/min/1.73m2 greatly increased in donors with either age >46, baseline eGFR <99, abnormal pre-donation blood pressure and decreasing preserved RV. Live kidney-donors who fall into these categories can be identified pre-donation, should be monitored closely post-donation and counseled accordingly.
The Best Practice in Live Kidney Donation Consensus Conference held in June of 2014 included the Best Practices in Living Donor Education Workgroup, whose charge was to identify best practice strategies in education of living donors, community outreach initiatives, commercial media, solicitation, and state registries. The workgroup's goal was to identify critical content to include in living kidney donor education and best methods to deliver educational content. A detailed summary of considerations regarding educational content issues for potential living kidney donors is presented, including the consensus that was reached. Educational topics that may require updating on the basis of emerging studies on living kidney donor health outcomes are also presented. Enhancing the educational process is important for increasing living donor comprehension to optimize informed decision-making.
Abstract Background Most centers perform some degree of hematologic screening, including thrombophilia testing, on prospective live liver donors. The nature and extent of such screens are not standardized, and there is limited evidence regarding hematologic risk stratification. Methods and Results We present an experience of hematologic screening among prospective liver donors. Five‐hundred‐eightyfour patients were screened for liver donation between 1/2013 and 1/2020, of whom 156 (27%) proceeded to donor hepatectomy. Thirty‐three of 428 (8%) declined patients were excluded for hematologic indications. Hematologic indications were the 2nd most frequent medical indications for exclusion (trailing only hepatologic indications). The most common reason for hematologic exclusion was concern regarding thrombophilia. Nevertheless, 21 patients with evidence of possible thrombophilia proceeded to donor hepatectomy, and none incurred hematologic complications. Similarly, seven patients with screening findings concerning for increased bleeding risk (most often thrombocytopenia) underwent donor hepatectomy without hematologic complication. Three of 156 (2%) of patients who underwent donor hepatectomy incurred a hematologic complication (all thrombotic, none fatal). None of these patients had any evident hematologic risk factor on screening. Conclusion This study underscores the difficulty of hematologic risk stratification among prospective living donors, however, suggests that some patients with relatively mild risk factors may be safe for donation.
Recurrence of hepatitis C is a significant problem after liver transplantation. This prospective study was done to assess the rate of recurrence and discuss two possible treatment modalities that have been successful in avoiding retransplantation. Twenty-one patients underwent orthotopic liver transplantation for hepatitis C at a metropolitan medical center over a 34-month period. The mean follow-up interval was 13.4 +/- 2.2 months (range 5-28 months). The patients were routinely evaluated with clinic visits and liver function tests, specifically total bilirubin, serum glutamic-oxaloacetic transaminase, and gamma-glutamyl transpeptidase. If values were elevated, the patient was admitted to the hospital for liver biopsy. Ten of the 21 patients demonstrated recurrence on biopsy. Two of 10 patients required no therapy. Interferon A was initiated in the remaining eight. Three of the eight patients had no significant response to interferon and were given intravenous ribavirin under an experimental protocol. Two of these three showed significant improvement in liver function values. The third died of chronic rejection. The incidence of recurrent hepatitis C after liver transplantation is significant. Many centers have had to resort to retransplantation. Our results show that with early detection and aggressive treatment with interferon and ribavirin, hepatitis C can be controlled and retransplantation may be avoided.
