End-of-Life issues and the patient with renal disease: an evidence-based practice project.

End-of-life issues affect everyone at some time. Individuals with chronic illness need to face these issues earlier to ensure their wishes are carried out. Patients with chronic kidney disease (CKD) Stage 5 have only three options: dialysis in its various forms, renal transplant, or death. In some cases, nurses who care for these patients feel they are caught between patients, their families, and the physician(s). Nurses want to help their patients but feel their hands are tied. The authors' evidence-based practice renal project team worked to answer the questions of how nurses can assist patients with end-of-life issues. Do patients with CKD Stage 5 receive enough information on quality of life and end-of-life issues? The evidence showed that nurses are not comfortable discussing end-of-life issues with their patients. In response to these data, several educational sessions designed to give nurses tools needed to develop a comfort level when discussing end-of-life issues with their patients were completed.

Characterization of in vitro antimurine thymocyte globulin-induced regulatory T cells that inhibit graft-versus-host disease in vivo.

Antithymocyte/antilymphocyte globulins are polyclonal antihuman T-cell antibodies used clinically to treat acute transplant rejection. These reagents deplete T cells, but a rabbit antihuman thymocyte globulin has also been shown to induce regulatory T cells in vitro. To examine whether antithymocyte globulin-induced regulatory cells might be functional in vivo, we generated a corresponding rabbit antimurine thymocyte globulin (mATG) and tested its ability to induce regulatory cells in vitro and whether those cells can inhibit acute graft-versus-host disease (GVHD) in vivo upon adoptive transfer. In vitro, mATG induces a population of CD4(+)CD25(+) T cells that express several cell surface molecules representative of regulatory T cells. These cells do not express Foxp3 at either the protein or mRNA level, but do show suppressive function both in vitro and in vivo when adoptively transferred into a model of GVHD. These results demonstrate that in a murine system, antithymocyte globulin induces cells with suppressive activity that also function in vivo to protect against acute GVHD. Thus, in both murine and human systems, antithymocyte globulins not only deplete T cells, but also appear to generate regulatory cells. The in vitro generation of regulatory cells by anti-thymocyte globulins could provide ad-ditional therapeutic modalities for immune-mediated disease.