KDIGO clinical practice guideline for the care of kidney transplant recipients: a summary.

The 2009 Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guideline on the monitoring, management, and treatment of kidney transplant recipients is intended to assist the practitioner caring for adults and children after kidney transplantation. The guideline development process followed an evidence-based approach, and management recommendations are based on systematic reviews of relevant treatment trials. Critical appraisal of the quality of the evidence and the strength of recommendations followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach. The guideline makes recommendations for immunosuppression and graft monitoring, as well as prevention and treatment of infection, cardiovascular disease, malignancy, and other complications that are common in kidney transplant recipients, including hematological and bone disorders. Limitations of the evidence, especially the lack of definitive clinical outcome trials, are discussed and suggestions are provided for future research. This summary includes a brief description of methodology and the complete guideline recommendations but does not include the rationale and references for each recommendation, which are published elsewhere.

Adequacy of dialysis: the patient's role and patient concerns.

The patient's role in adequacy of hemodialysis is demanding and complex. It requires meticulous attention to initiating, accepting, and maintaining extraordinary behavioral change. This includes the following: (1) major alteration of dietary habits, often contrary to a patient's familial and cultural customs; (2) compliance with a new, voluminous medication routine, often straining personal finances; (3) reallocation of time for transportation, treatment, and partial recovery, frequently consuming a minimum of 6 to 8 hours 3 days each week; (4) psychologic adjustment to unaccustomed chronic dependency on, and accountability to, an array of variably experienced and competent renal care staff; (5) skills, seldom taught, required to communicate clearly and regularly with overworked medical professionals who are often much younger with less life experience; and (6) additional commitment to compensating for the physical fatigue that routinely accompanies hemodialysis. Reasonable behavioral modification in these 6 categories is likely to increase the chances of a patient fulfilling his role in adequacy of dialysis. Some patients, however committed the staff have been in assisting them, may show little interest in dialysis adequacy and the patient's role. Other patients periodically may fail in their role unless the renal care team recognizes the patient as an individual who is included as an important team member. The patient requires consistent and repeated education about their disease, treatment, and risks and benefits of adherence. The unique, unnatural requirements of adequate chronic hemodialysis require this patient support from the renal staff, enhanced by continuous sensitive attention, empathy, and persuasion. This will help the patient achieve success in their role.

Prevalence and outcomes of multiple-listing for cadaveric kidney and liver transplantation.

Transplant candidates are permitted to register on multiple waiting lists. We examined multiple-listing practices and outcomes, using data on 81 481 kidney and 26 260 liver candidates registered between 7/1/95 and 6/30/00. Regression models identified factors associated with multiple-listing and its effect on relative rates of transplantation, waiting list mortality, kidney graft failure, and liver transplant mortality. Overall, 5.8% (kidney) and 3.3% (liver) of candidates multiple-listed. Non-white race, older age, non-private insurance, and lower educational level were associated with significantly lower odds of multiple-listing. While multiple-listed, transplantation rates were significantly higher for nearly all kidney and liver candidate subgroups (relative rate [RR]= 1.42-2.29 and 1.82-7.41, respectively). Waiting list mortality rates were significantly lower while multiple-listed for 11 kidney subgroups (RR = 0.22-0.72) but significantly higher for 7 liver subgroups (RR = 1.44-5.93), suggesting multiple-listing by healthier kidney candidates and sicker liver candidates. Graft failure was 10% less likely among multiple-listed kidney recipients. Multiple- and single-listed liver recipients had similar post-transplant mortality rates. Although specific factors characterize those transplant candidates likely to multiple-list, transplant access is significantly enhanced for almost all multiple-listed kidney and liver candidates.

ESRD patient quality of life: symptoms, spiritual beliefs, psychosocial factors, and ethnicity.

BACKGROUND: Recent research suggests that patients' perceptions may be more important than objective clinical assessments in determining quality of life (QOL) for patients with end-stage renal disease (ESRD). METHODS: We interviewed 165 hemodialysis patients from 3 sites using a QOL questionnaire that included the Satisfaction With Life Scale (SWLS) and the McGill QOL (MQOL) scale, which includes a single-item global measure of QOL (Single-Item QOL Scale [SIS]). The MQOL scale asks patients to report their most troublesome symptoms. We also initiated the use of a Support Network Scale and a Spiritual Beliefs Scale. RESULTS: Mean patient age was 60.9 years, 52% were men, 63% were white, and 33% were African American. Patients had a mean treatment time for ESRD of 44 months, mean hemoglobin level of 11.8 g/dL (118 g/L), mean albumin level of 3.7 g/dL (37 g/L), and mean Kt/V of 1.6. Forty-five percent of patients reported symptoms. Pain was the most common symptom (21% of patients). There was an inverse relationship between reported number of symptoms and SWLS (P < 0.01), MQOL scale score (P < 0.001), and SIS (P < 0.001). The Spiritual Beliefs Scale correlated with the MQOL scale score, SWLS (both P < 0.01), and SIS (P < 0.05). The Support Network Scale score correlated with the MQOL Existential (P = 0.01) and MQOL Support (P < 0.01) subscales. No clinical parameter correlated with any measure of QOL, spiritual beliefs, or social support. CONCLUSION: Symptoms, especially pain, along with psychosocial and spiritual factors, are important determinants of QOL of patients with ESRD. Additional studies, particularly a longitudinal trial, are needed to determine the reproducibility and utility of these QOL measures in assessing patient long-term outcome and their association with other QOL indices in larger and more diverse patient populations.