ABSTRACT
The success of renal, liver, cardiac, pulmonary, and other solid organ transplantation (SOT) has resulted in increasing volume of transplant procedures and recipient survivorship. Subsequently, many SOT patients develop end-stage degenerative joint disease and are presenting for total hip or total knee arthroplasty more frequently. Surgeons must be aware of the medical complexities and prepare for the perioperative risks associated with these immunocompromised patients. Preoperative evaluation should be conducted in coordination with transplant specialists to ensure optimization, including appropriate surgical timing and advanced, organ-specific medical assessments. Although often unable to be modified, the transplant patient's antirejection medication regimens should be reviewed with understanding of inherent risks of poor wound healing or acute infection. Despite higher rates of complications, revision surgeries, and mortality compared with the general population, SOT recipients continue to demonstrate markedly improved pain relief, function, and quality of life. An ongoing multidisciplinary approach is required throughout the perioperative process and beyond to deliver successful outcomes after total joint arthroplasty in the SOT population.
Subject(s)
Arthroplasty, Replacement, Knee , Organ Transplantation , Humans , Quality of LifeABSTRACT
We identified an educational deficit among clients at a community health clinic regarding the latest cervical cancer screening recommendations. A literature search on Pap testing and problems with compliance or screening indicated multiple barriers to cervical cancer screening. Education, health promotion and the use of a hand-held health card/record were identified as methods to educate women regarding cervical cancer prevention. We developed a hand-held Pap test card to be similar to an immunization card. The card was designed to fulfill the needs of both clients and practitioners.
Subject(s)
Mass Screening/methods , Papanicolaou Test/methods , Patient Education as Topic , Uterine Cervical Neoplasms/diagnosis , Early Detection of Cancer , Female , Guideline Adherence , Health Promotion/methods , Humans , Mass Screening/nursing , Papanicolaou Test/nursing , Papanicolaou Test/standards , Patient Compliance , Quality Improvement , Reminder Systems , Uterine Cervical Neoplasms/nursing , Uterine Cervical Neoplasms/prevention & controlABSTRACT
BACKGROUND: Broad-based formal quality improvement curriculum emphasizing Six Sigma and the DMAIC approach developed by our institution is required for physicians in training. DMAIC methods evaluated the common outcome of postoperative hyponatremia, thus resulting in collaboration to prevent hyponatremia in the renal transplant population. METHODS: To define postoperative hyponatremia in renal transplant recipients, a project charter outlined project aims. To measure postoperative hyponatremia, serum sodium at admission and immediately postoperative were recorded by retrospective review of renal transplant recipient charts from June 29, 2010 to December 31, 2011. An Ishikawa diagram was generated to analyze potential causative factors. Interdisciplinary collaboration and hospital policy assessment determined necessary improvements to prevent hyponatremia. Continuous monitoring in control phase was performed by establishing the goal of <10% of transplant recipients with abnormal serum sodium annually through quarterly reduction of hyponatremia by 30% to reach this goal. RESULTS: Of 54 transplant recipients, postoperative hyponatremia occurred in 92.6% of patients. These potential causes were evaluated: 1) Hemodialysis was more common than peritoneal dialysis. 2) Alemtuzumab induction was more common than antithymocyte globulin. 3) A primary diagnosis of diabetes existed in 16 patients (30%). 4) Strikingly, 51 patients received 0.45% sodium chloride intraoperatively, suggesting this as the most likely cause of postoperative hyponatremia. A hospital policy change to administer 0.9% sodium chloride during renal transplantation resulted in normal serum sodium levels postoperatively in 59 of 64 patients (92.2%). CONCLUSION: The DMAIC approach and formal quality curriculum for trainees addresses core competencies by providing a framework for problem solving, interdisciplinary collaboration, and process improvement.
Subject(s)
Hyponatremia/prevention & control , Kidney Transplantation , Postoperative Complications/prevention & control , Quality Improvement , Competency-Based Education , Humans , Hyponatremia/epidemiology , Incidence , Interdisciplinary Communication , Postoperative Complications/epidemiology , Problem-Based Learning , Retrospective Studies , United States/epidemiologyABSTRACT
Nonadherence of transplant recipients to prescribed medical regimens has been identified as a major cause of allograft failure. Although recent studies offer new insight into the clinical phenotypes of nonadherence, advances in defining risk factors and appropriate interventions have been limited because of variable definitions, inadequate clinical metrics, and the challenges associated with healthcare delivery. Significant nonadherence is estimated to occur in 22% of renal allograft recipients and may be a component of allograft loss in approximately 36% of patients. It is associated with increased incidence of rejection (acute and chronic) and, consequently, shortened renal allograft survival, requiring reinstitution of costly chronic renal replacement therapy with an incumbent effect on morbidity and mortality. The economic effect of nonadherence approaches similar magnitude. Identification of risk factors, coupled with measures that effectively address them, can have a positive effect at many levels--medically, socially, and economically. Further advances are likely to be dependent on improving interactions between patients and caregivers, broadening immunosuppressant availability, and newer therapeutics that move toward simpler regimens.
Subject(s)
Graft Rejection/prevention & control , Graft Survival/drug effects , Immunosuppressive Agents/therapeutic use , Kidney Transplantation , Medication Adherence , Cost Savings , Graft Rejection/economics , Graft Rejection/immunology , Health Behavior , Health Care Costs , Health Knowledge, Attitudes, Practice , Humans , Immunosuppressive Agents/economics , Kidney Transplantation/adverse effects , Kidney Transplantation/economics , Risk Factors , Transplantation, Homologous , Treatment OutcomeABSTRACT
Bortezomib can be used to successfully treat acute kidney injury in the renal transplant allograft due to light chain cast nephropathy from recurrent multiple myeloma.
Subject(s)
Boronic Acids/therapeutic use , Kidney Failure, Chronic/surgery , Kidney Transplantation/immunology , Multiple Myeloma/complications , Protease Inhibitors/therapeutic use , Pyrazines/therapeutic use , Adult , Alemtuzumab , Antibodies, Monoclonal/therapeutic use , Antibodies, Monoclonal, Humanized , Antibodies, Neoplasm/therapeutic use , Biopsy , Bone Marrow/immunology , Bone Marrow/pathology , Bortezomib , Female , Humans , Immunoglobulin kappa-Chains/analysis , Immunosuppressive Agents/therapeutic use , Kidney Transplantation/pathology , Living Donors , Mycophenolic Acid/analogs & derivatives , Mycophenolic Acid/therapeutic use , Recurrence , Syndecan-1/analysis , Tacrolimus/therapeutic useABSTRACT
Obstacles to the widespread use of continuous renal replacement therapy (CRRT) include the need for anticoagulation, customized solutions, and complex protocols that carry an attendant risk for error, raise cost, and increase pharmacy and nursing workload. However, high solute clearance using CRRT with an effluent rate of 35 ml/kg per h has also recently been associated with improved survival in critically ill patients with acute renal failure. No published CRRT protocols using dilute regional citrate anticoagulation have achieved adequate metabolic control, effective anticoagulation, and high solute clearance in a practical, user-friendly, and economical manner. The safety and the efficacy of continuous venovenous hemodiafiltration at effluent rates of 35 ml/kg per h in critically ill acute renal failure patients were evaluated prospectively using a standardized bicarbonate-based dialysate; a systemic calcium infusion; and two separate trisodium citrate replacement solutions, a 0.67% solution and a 0.5% solution. All patients achieved adequate metabolic control, the desired effluent rate of 35 ml/kg per h, and high solute clearance. Use of the 0.67% citrate replacement solution resulted in mild alkalosis, whereas the 0.5% solution maintained appropriate acid-base balance. There was no difference in dialyzer survival between the 0.67 and 0.5% citrate groups (80 versus 82%; P = 0.60, Kaplan-Meier analysis). Dilute regional citrate as part of a CRRT protocol with a standard 25-mmol/L bicarbonate dialysate provides adequate metabolic control, high diffusive and convective clearance, and excellent dialyzer patency in a practical and cost-effective manner.