Life satisfaction in renal transplant recipients: preliminary results from the transplant learning center.

The Transplant Learning Center (TLC) was designed to improve quality of life (QOL) and preserve graft function in solid-organ transplant recipients. To meet the specific goals of the program, the Life Satisfaction Index and Transplant Care Index were designed to serve as composite measures for measuring transplant-specific QOL and the ability to care for a transplant, respectively. In this study, we analyzed self-reported health information to examine relationships between comorbidities and individual posttransplantation side effects, life satisfaction, and transplant care, defined by renal transplant recipients. Patients entered the TLC through self-referral or referral by a health professional. Included in the analysis were 3,676 TLC enrollees with a mean time since transplantation of 4.8 years. Comorbidities and adverse effects were common, with high blood pressure reported by 89% of respondents and unusual hair growth reported by 70%. Sexual dysfunction and headache had a greater impact on QOL than more common adverse effects, such as changes in body and facial shape, hirsutism, and tremor. Regression modeling was used to identify the most significant associations between QOL indices and structural (nonmedical), medical, and psychosocial factors. Greater life satisfaction was most strongly associated with being in control of one's health and living a normally active life with satisfying emotional relationships. Management of such clinical problems as adverse effects of medication and nonadherence should be informed by the patient's perspective. Clinicians should actively solicit information about physical activity, appearance concerns, side effects of medications, nonadherence, and sexual and relationship issues when evaluating renal transplant recipients.

Evaluation of a multivariate model predicting noncompliance with medication regimens among renal transplant patients.

BACKGROUND: Because noncompliance with medication regimens is a major cause of renal allograft failure, we evaluated the stability over time of two logistic regression models (sets of variables) that predict noncompliance with immunosuppressive regimens. METHODS: Models were based on questionnaire data from 1402 patients (all over 18, receiving cyclosporine or a cyclosporine-like replacement drug, and with a functioning renal graft). The same questionnaire was completed by a subset of 548 (39.1%) patients approximately 18 months later. The goodness of fit of each model to the new data set was tested. RESULTS: The noncompliance logistic regression model including patient beliefs as well as patient and transplant characteristics was an excellent fit to the second data set. A noncompliance model composed of only patient and transplant characteristics fit the new data set less well. CONCLUSIONS: Clinicians and educators need to take explicit account of renal transplant patients' attitudes when evaluating risks of noncompliance and when developing interventions and educational programs to minimize noncompliance.

Compliance and noncompliance in kidney transplant patients: cues for transplant coordinators.

Maximizing kidney transplant patients' long-term compliance with immunosuppressants is a major challenge to transplant coordinators. Although previous research has found substantial proportions of recipients to be noncompliant, predictors of noncompliance and characteristics of noncompliers remain unclear. In this study of more than 1400 kidney transplant patients, we found noncompliance to be associated with patient and transplant characteristics and with patient beliefs concerning the efficacy of immunosuppressants. Three distinct profiles of noncompliers were identified: accidental noncompliers, invulnerables, and decisive noncompliers. This information can be used by transplant coordinators to recognize cues that predict noncompliance and to work with at-risk patients to forestall or remedy noncompliant behavior.

Compliance and noncompliance in patients with a functioning renal transplant: a multicenter study.

BACKGROUND: Noncompliance with medication is a major cause of renal allograft failure among adult renal transplant patients. We summarize previous studies of noncompliance and report results of a large, multicenter survey designed to identify variables that (1) affect the likelihood of compliance with immunosuppressive medication regimens and (2) distinguish among noncompliant patients. METHODS: Questionnaires were distributed to 2500 patients at 56 U.S. transplant centers. Compliance was determined by patient responses to questions concerning whether, within the previous 4 weeks, one or more doses of immunosuppressive medications had been missed. Independent variables included patient and transplant characteristics, memories of dialysis, posttransplant symptoms and beliefs, and beliefs concerning the efficacy and importance of immunosuppressants. RESULTS: The incidence of noncompliance reported by the 1402 respondents was 22.4%. A logistic regression model that included age, occupation, time since transplant, and three medication-related beliefs was most predictive of the likelihood of compliance. Donor type and histories of diabetes and of infection entered the multivariate model when belief-related variables were excluded. Cluster analyses identified three distinct profiles of noncompliers: accidental noncompliers, invulnerables, and decisive noncompliers. CONCLUSIONS: Results of this study, which included nearly three times more patients than the largest previously reported study, can be used by clinicians to identify patients likely to become noncompliant, by researchers to develop randomized, prospective clinical trials of interventions designed to increase compliance, and by educators to tailor patient education programs.

Postrenal transplant compliance from the perspective of African-Americans, Hispanic-Americans, and Anglo-Americans.

Medication compliance by patients is a subject that has attracted attention because it has been identified as the third leading cause of renal graft loss. The purpose of this study was to gather specific information about renal-transplant recipients' cognitions, emotions, and behaviors during the postrenal transplant compliance process. Data from 519 renal transplant patients were collected through mailed surveys; chart audits were conducted for 397 patients in the sample. Findings revealed that 96 (18%) of the transplant recipients had been noncompliant with immunosuppressive medications. Factors related to noncompliance included being away from home, length of time since transplant, age, gender, and ethnicity, as well as patients' beliefs regarding how long posttransplant symptoms would persist and their beliefs about the effectiveness of immunosuppressive medications. Of particular interest were the findings related to compliance by African-American patients, which challenge conventional thinking. Implications for assessing patient compliance, patient education, and further research are discussed.

Colchicine prevents kidney transplant amyloidosis in familial Mediterranean fever.

Twenty-one familial Mediterranean fever (FMF) patients who received a kidney transplant for terminal renal failure due to amyloidosis were studied retrospectively to evaluate the prophylactic effect of colchicine on graft amyloidosis. Proteinuria, highly suggestive of kidney transplant amyloidosis, developed in 11 patients within a median of 3 years after transplantation (range 0.5-10 years). In 10 patients, repeated urinalyses for protein were negative during a median of 5 years after transplantation (range 1-13). Patients who developed proteinuria or transplant amyloidosis received smaller colchicine doses than patients without proteinuria--mean 0.69 (range 0-1) versus 1.53 (range 1-2) milligrams per day (p = 0.0002), suggesting that colchicine prevents or delays development of transplant amyloidosis. This prophylactic effect of colchicine was complete at a dose of 1.5 mg/day or more and absent at a daily dose of 0.5 mg or less. In patients who received 1 mg/day, individual variability in the response to colchicine was observed. We conclude that the development of amyloidosis of the kidney transplant in FMF is inevitable at a colchicine dose lower than 1 mg/day, unpredictable at 1 mg/day and usually preventable with 1.5 mg/day or more.

Moving beyond: a generative philosophy of science.

Philosophies of science are perhaps the most covert yet significant forces influencing the direction of change within disciplines. Although the era of logical positivism has waned for many disciplines, newer philosophies may not be satisfactory, especially for the applied disciplines. This article describes an alternative philosophy of science with special significance for nursing. This philosophy was influenced by several of the major existing philosophies, but especially by the paradigmatic view espoused by Thomas Kuhn. The generative philosophy of science was named because of its focus on generating growth among the applied disciplines. Members of these disciplines study questions with social significance and human application. This article defines major concepts, describes relationships among concepts and discusses implications for the development of nursing science and the nursing discipline.

Kaposi's sarcoma in immunosuppression. Possibly the result of a dual viral infection.

Kaposi's sarcoma of the gingiva and skin developed in an HIV-negative renal transplant patient while he was receiving cyclosporine therapy. The Kaposi's sarcoma developed shortly after the patient had an acute infection with cytomegalovirus (CMV). Electron microscopy of the tumor's established cell line showed two types of virus-like particles. CMV DNA was identifiable in the cell line whereas infectious CMV could be isolated only after repeated passages (only after 3 months of culture). The other virus could not be identified, but did not appear to be either HIV or papilloma virus. The patient's tumor regressed after the discontinuation of cyclosporine therapy and the recovery from the acute CMV infection.

The fate of the freeze-preserved xenograft: an experimental study on rabbits, cats, and dogs.

Freeze-preserved allografts have been used successfully in patients for vascular peripheral replacement, dialysis, and chemotherapy. Freezing of veins seems to decrease or abolish antigenicity by decreasing the viable cellular components of the grafts. To confirm its acceptance and consequently, the high patency rates of freeze-preserved vein grafts, we inserted segments of human veins preserved at -80 degrees Centigrade as arterial substitutes into rabbits, cats, and dogs and studied the morphological changes of these xenografts up to 2 years. In all the groups, the patency rate was satisfactory. In rabbits and dogs, the cellular inflammatory reaction around the grafts and suture lines disappeared after a few weeks; the endothelium was reconstructed at 2 months and a poorly differentiated cellular fibro-collagenous wall with prominent hyalin matrix was observed. In cats, however, the histio-lymphocytic infiltrate persisted in functioning grafts up to 2 years associated with adjacent prominent vascular and nerve proliferation. It is suggested that this inflammatory reaction has no deleterious effect on the graft; on the contrary, it promotes its neovascularisation and innervation. The cat proved to be a good animal model for vascular surgical experiments. Our study proved the poor antigenicity of freeze-preserved venous xenograft. It could, in the future, be used for human arterial substitutes.