[show abstract][hide abstract] ABSTRACT: Hepatitis C virus (HCV) is a risk factor for developing posttransplantation diabetes mellitus (PTDM) after liver transplantation; little is known about the biological mechanisms involved with this risk. This study investigated gene expression differences to provide insight into potential mechanisms.
Gene expression profiles of blood samples obtained from 6 HCV+ liver transplant recipients were determined using Affymetrix U133 Plus 2.0 microarrays. Differential gene expression was assessed between HCV+ recipients with PTDM (n = 3) and without PTDM (n = 3) using the GeneSpring 7.3 software package. The Welch t test was used to identify significant differences (P < .05) between groups. Gene expression profiles for 6 HCV- liver transplant recipients (with PTDM = 3, without PTDM = 3) were used as a blind test set to evaluate a subset of genes to predict PTDM.
Expression levels of 347 genes were significantly different between recipients with PTDM and those without PTDM. Seventy-four genes were up-regulated and 270 were down-regulated in PTDM. Genes were categorized into functional classes: apoptosis (n = 69 genes); immune function (n = 110); diabetes (n = 17); hepatitis C (n = 12); liver transplant (n = 69). The expression profile of a subset of genes was evaluated for predicting PTDM in 6 HCV- transplant recipients. We accurately predicted the presence or absence of PTDM in 5/6 recipients.
PTDM in HCV+ liver transplant recipients was associated with down-regulated expression of a large number of genes. A subset of these genes was useful to predict PTDM in HCV- recipients. Most genes were associated with apoptosis and immune function. HCV may act as a primer by affecting a group of genes involved in developing diabetes.
[show abstract][hide abstract] ABSTRACT: This pilot study examined associations among patterns of gastric myoelectrical activity, symptoms of gastroparesis, years of diabetes, months of dialysis, and use of gastrointestinal medications in gastroparetic kidney-pancreas (KP) transplant recipients. Electrogastrography (EGG) and gastric symptom data were obtained from 42 transplant recipients before and after transplant (6, 12, and 24 months). Recipients were 38 +/- 7 yr of age, 88% Whites, and 60% male; 97% had hypertension. All had functioning grafts post-transplant (mean creatinine, 1.59 +/- 0.66 mg/dL, and serum glucose 91.97 +/- 24.92 mg/dL). Sixteen subjects had normal EGG (2.7-3.2 cycles per minute, cpm); two were tachygastric (>3.2 cpm) at all time points; one remained bradygastric (<2.7 cpm) throughout the study period. Following transplant, symptoms lessened and were associated with 6-month normalization of EGG (r = 0.41, p = 0.02). A small change in the percentage of patients with normal EGG was observed from baseline to 24 months (67% vs. 69% respectively); however, there was a shift from bradygastria (29% to 15% respectively) to tachygastria (5% to 15% respectively). Prescribed prokinetic and antisecretory medications use increased over the study period from 13 (31%) subjects at baseline to 32 (86%) at 6 months; 21 (78%) at 12 months; and 12 (92%) at 24 months. Although symptoms diminish following transplant, gastroparesis remains a significant problem for transplant patients. Normalization of EGG and shifts from bradygastria to tachygastria occur post-transplant. Our results suggest that serial EGGs and frequent assessment of symptoms can be used to follow gastroparesis in KP recipients.
[show abstract][hide abstract] ABSTRACT: A novel technique of pancreas transplantation (PTX) with portal venous delivery of insulin and enteric exocrine drainage (portal enteric) was developed at our center to improve the PTX procedure.
Single-center experience at a university hospital.
From October 1990 through December 1999, we performed 126 PTXs with portal enteric drainage, including 90 simultaneous kidney PTXs (SKPT) and 36 solitary PTXs (18 sequential PTXs after kidney transplantation and 18 PTXs alone).
Patient and graft survival rates; medical and surgical morbidity. Three groups, representing 3 eras of immunosuppression, were compared. Thirty patients underwent SKPT with muromonab-CD3 induction and cyclosporine-based therapy in era 1 (October 1990 through June 1995); 42 SKPTs received tacrolimus and mycophenolate mofetil-based immunosuppression without antibody induction in era 2 (July 1995 through May 1998); and 18 SKPTs were performed in era 3 (June 1998 through December 1999) with either basiliximab or daclizumab induction.
One-year patient survival rates after SKPT were 77% in era 1, 93% in era 2, and 100% in era 3 (P =.03). The 1-year kidney graft survival rates were 77% in era 1, 93% in era 2, and 94% in era 3 (P =.08). The 1-year pancreas graft survival rates after SKPT were 60% in era 1, 83% in era 2, and 83% in era 3 (P =.06). The incidences of rejection (63% vs. 33% vs. 39%; P<.001) and thrombosis (20% vs. 7% vs. 6%; P<.001) were decreased in eras 2 and 3.
Simultaneous kidney PTXs with portal enteric drainage can be performed with improved outcomes.
Archives of Surgery 11/2001; 136(10):1141-9. · 4.10 Impact Factor
[show abstract][hide abstract] ABSTRACT: The Internet is a global communication network used by more than 17.6 million adults as a major source of current health information. Both the number of health-related Web sites and the number of Web users are increasing exponentially as well as reports indicating a growth in the number of persons who access the Internet specifically to retrieve information about organ transplantation. However, few are using this medium for posttransplant educational or psychosocial purposes. Armed with this information, as well as a commitment from the transplant team, we chose to develop a Web-based educational program to facilitate posttransplant care for our transplant recipients. The purpose of this article is to describe the planning, development, and implementation of a Web-based education program for transplant recipients.
[show abstract][hide abstract] ABSTRACT: A self-assessment instrument for use at home by transplant recipients was developed to help foster partnership between patients and their healthcare provider. Self-monitoring at home has not replaced the need for close follow-up but does allow patients to provide concrete data to their healthcare provider in order to promote earlier detection of and response to adverse events. Patients are taught the essentials of self-monitoring while they are in the hospital for their transplant. Patients who perform routine self-assessment would be able to detect and provide information about problems early in the course of events. Thus, early intervention could potentially decrease the severity of the problem and prevent repeated hospitalizations. The concern that patients would not be able to perform a reliable self-assessment was unfounded; patients exceeded expectations and embraced the opportunity to communicate physical signs and symptoms effectively.
[show abstract][hide abstract] ABSTRACT: We retrospectively reviewed long-term outcomes in simultaneous kidney-pancreas transplant (SKPT) recipients with portal-enteric (P-E) versus systemic-bladder (S-B) drainage. Forty-five patients were alive with functioning grafts 1 year after SKPT and were followed up for a minimum of 3 years (mean, 5.9 years), including 26 patients with P-E drainage and 19 patients with S-B drainage. Recipient demographic and transplant characteristics were similar between the two groups. In both groups, hospital admissions decreased significantly with increasing time after SKPT, although significantly fewer readmissions occurred in the first year in the P-E than the S-B group. The most common reason for readmission in both groups was infection, followed by miscellaneous, surgical, and immunologic morbidity. The incidence of readmission for dehydration was significantly less in the P-E group (P < 0.01). Mean systolic and diastolic blood pressures were similar between groups, although the number of antihypertensive medications was significantly less in the S-B group. Although fasting C-peptide levels were significantly greater in the S-B group, the two groups were similar with regard to carbohydrate (fasting serum glucose, hemoglobin A(1c)) and lipid (total cholesterol) metabolism. Renal and pancreas allograft functions were similar between the two groups. At 1 year post-SKPT, stabilization in most diabetic complications was reported. Four quality-of-life surveys that provided 29 scores were completed 6 to 24 months (mean, 18.5 months) after SKPT. Improved quality of life was reported in all but one of the scales, with many dimensions showing significant improvements. At 3 years after SKPT, no activity limitation was reported in 76% of patients with P-E drainage versus 53% with S-B drainage (P = 0.11). Five-year actual patient, kidney, and pancreas graft survival rates after P-E versus S-B drainage are 92% and 84%, 81% and 79%, and 88% and 74%, respectively (P = not significant). SKPT with P-E drainage is a safe and effective method to treat advanced diabetic nephropathy and is associated with decreasing morbidity, improving rehabilitation and quality of life, and stablizing metabolic function over time. The long-term prognosis after the first year is excellent and at least similar to the results achieved with S-B drainage.
American Journal of Kidney Diseases 07/2001; 38(1):132-43. · 5.29 Impact Factor
[show abstract][hide abstract] ABSTRACT: The return to work after transplantation has been actively discussed in the transplant community for years. However, despite the desire for transplant practitioners to have recipients return to being healthy, contributing members of society as well as return to work, practitioners often passively support the sick role. We discovered that patients who are returning to work after transplantation may have been out of the work force for several years, and require assistance that we as health care providers were unable or untrained to provide. An employment specialist was added to the transplant staff and became a vital part of our attempts to create a proactive employment atmosphere and enhance our patients' quality of life. Adding an advocate for employment in our center has also facilitated the shift in our thinking and approach to care from the sick role to one of rehabilitation and from reactive to proactive. This change in attitude has assisted in empowering our recipients to feel as if they can truly resume a normal life.
[show abstract][hide abstract] ABSTRACT: Persons with end-stage renal disease have an accelerated risk for cardiovascular (CV) morbidity and mortality. Unfortunately, their accelerated CV risk persists even after kidney transplantation associated with pretransplant and post-transplant vascular disease. number of rejections treated with high-dose steroids, prolonged use of immunosuppressive therapy post-transplant, effects of comorbid chronic conditions and male gender. Unhealthy, modifiable lifestyle practices often augment their CV risk. The purpose of this study was to examine health-related lifestyle behaviors and estimate CV risks of men 1 year following kidney transplantation. Using the Healthier People Network Health Risk Appraisal (HPN-HRA), we examined CV risk characteristics of 34 men (M age=47.3 years) enrolled in an urban, mid-southern transplant center. Participants were assessed via self-administered paper-and-pencil questionnaires and medical record review provided biological data for analyses. HPN-HRA software was used to analyze biological and behavioral characteristics to compute CV risk estimates. Data were analyzed using descriptive, inferential and correlational analyses. The majority of participants reported smoke cessation (n= 19) or never having smoked (n = 8), and consumption of one or less alcoholic drinks per week (n=28). On the other hand, increased risk for heart attack and stroke were associated with advancing age (P<0.0001), white race (P<0.05) and higher systolic blood pressure (P<0.01). While risk for heart attack was associated with current cigarette smoking (P<0.01), risk for stroke was not. Conversely, risk for stroke was associated with higher BMI (P<0.05), risk for heart attack was not. Thus, the study provides evidence that male kidney transplant survivors exhibit a significant number of non-modifiable and modifiable characteristics that contribute to their posttransplant CV risk.
[show abstract][hide abstract] ABSTRACT: Transplantation has enhanced the quality of life of all transplant recipients, but concern remains regarding the side effects of immunosuppressant drugs. In order to respond to these concerns, a survey to ascertain the side effect profile of transplant recipients was undertaken to identify the impact of chronic immunosuppression on quality of life. A nationwide survey of solid organ transplant recipients was carried out using a newly developed immunosuppressant side effect survey. Kidney, kidney-pancreas, liver and heart recipients responded to the survey (n = 505) and reflect the national distribution based on the UNOS data for organ type, recipient race and gender. The survey had four subscales: emotional burden, life/role responsibilities, mobility and GI distress. A fifth subscale included miscellaneous side effects that are more prevalent during the first 2 years post-transplant. Frequency and severity of each side effect were coded on a scale of 0-4 from 'no problem' to 'always' a problem. The entire range of possible scores (0-160) was reported, reflecting adequate variability in the responses. The sample consisted of 51% males, 77% Caucasians, 15% African Americans, with the remaining 8% other races. There were 225 (44.5%) kidney, 147 (29.1%) liver, 101 (20%) heart and 32 (6.4%) pancreas included. Age ranged from 18-71 years with time since transplant 1-21 years. Overall frequency (12.1 +/- 6.08), severity (10.5 +/- 6.96) and weighted scores (25.4 +/- 19.9) were low suggesting that, as a whole, immunosuppressant side effects, while present, were not severe or troublesome for most patients. Side effect profiles appeared similar among organ types. Differences were detected in the GI distress subscale with the heart recipients reporting significantly less GI distress than liver recipients (13.8 vs. 19.2; P<0.05). Side effect impact on mobility tended to increase between time eras; however, no statistical significance was detected. Side effects are a concern among health-care professionals; however, based on the results of this study, immunosuppressant-related side effects are not detrimental to quality of life and show no differences between types of organ transplanted.
[show abstract][hide abstract] ABSTRACT: A prospective evaluation of 37 kidney and 20 kidney-pancreas transplant recipients was conducted to assess the relationship between pre- to posttransplant changes in heart rate variability (HRV) and quality of life (QoL). Assessments of 24-hour interbeat variability (pNN50 and rMSSD, SDNN, SDANN) and power spectral analysis of total, low (sympathetic), and high (parasympathetic) frequency components of HRV were performed. The Sickness Impact Profile was used to assess three dimensions of QoL (physical, psychosocial, and total functioning) prior to and at 6 months following transplantation. Changes in vagally mediated time domain measures of HRV were related to changes in physical and total functioning. Stronger correlations occurred between biobehavioral measures in kidney-pancreas recipients, with the strongest relationships occurring between changes in HRV frequency domain measures and changes in physical functioning. Findings indicate that changes in HRV and QoL are related, suggesting that interventions that enhance transplant recipients' HRV may also enhance their QoL.
Western Journal of Nursing Research 11/2000; 22(6):749-68. · 1.22 Impact Factor
[show abstract][hide abstract] ABSTRACT: The purposes of this study were to identify the level of subjective burden reported by African American caregivers of patients diagnosed with end stage renal disease (ESRD) awaiting transplantation and identify whether subjective burden, personal strain, and role strain varied by caregiver age. An exploratory descriptive survey design was used. The convenience sample consisted of 78 African American family caregivers. Subjects were obtained from a University transplant clinic in the Mid-South. Caregivers completed the 22-item self-administered Burden Interview (BI) and a demographic data form. Data were analyzed using descriptive statistics and the appropriate parametric and nonparametric tests of group differences. Most caregivers, reported little to none or mild to moderate burden. Results also indicated that there was no significant difference in the level of overall burden, personal strain, and role strain reported by young and older caregivers. Additional findings revealed that burden was least in the caregivers of patients who independently performed activities of daily living (ADL) and greatest among the caregivers of patients assisted by someone other than the caregiver with ADL. Findings from this study may help nurses to assist caregivers to identify their level of burden early in the caregiving process. Implementation of early interventions may prevent negative psychological and physical outcomes in these caregivers.
Nephrology nursing journal: journal of the American Nephrology Nurses' Association 09/2000; 27(4):383-91, 355; discussion 392, 405.
[show abstract][hide abstract] ABSTRACT: To examine how the choice of surgical technique influenced perioperative outcomes in liver transplantation.
The standard technique of orthotopic liver transplantation with venovenous bypass (VVB) is commonly used to facilitate hemodynamic stability. However, this traditional procedure is associated with unique complications that can be avoided by using the technique of liver resection without caval excision (the piggyback technique).
A prospective comparison of the two procedures was conducted in 90 patients (34 piggyback and 56 with VVB) during a 2.5-year period. Although both groups had similar donor and recipient demographic characteristics, posttransplant outcomes were significantly better for the patients undergoing the piggyback technique. The effect of surgical technique was examined using a stepwise approach that considered its impact on two levels of perioperative and postoperative events.
The analysis of the first level of perioperative events found that the piggyback procedure resulted in a 50% decrease in the duration of the anhepatic phase. The analysis of the second level of perioperative events found a significant relation between the anhepatic phase and the duration of surgery and between the anhepatic phase and the need for blood replacement. The analysis of the first level of postoperative events found that the intensive care unit stay was significantly related to both the duration of surgery and the need for blood replacement. The intensive care unit stay was in turn related to the second level of postoperative events, namely the length of hospital stay. Finally, total charges were directly related to length of hospital stay. The overall 1-year actuarial patient and graft survival rates were 94% in the piggyback and 96% in the VVB groups, respectively.
These data demonstrate that surgical choices in complex procedures such as orthotopic liver transplantation trigger a chain of events that can significantly affect resource utilization. In the current healthcare climate, examination of the sequence of events that follow a specific treatment may provide a more complete framework for choosing between treatment alternatives.
Annals of Surgery 07/2000; 231(6):814-23. · 6.33 Impact Factor
[show abstract][hide abstract] ABSTRACT: Cardiac autonomic function has been associated with mortality in patients with end-stage renal disease. It is unknown whether end-stage renal disease patients who have succumbed to sudden cardiac death can be better identified by a newer test of heart rate variability that uses spectral analysis, rather than laboratory evoked measures.
This series of studies sought to characterize cardiac autonomic function in patients awaiting kidney transplantation, identify factors associated with heart rate variability, identify tests which distinguish patients at-risk for death, and compare evoked measures with 24-hour heart rate variability measures.
Data were collected on 184 nondiabetics, 60 type 1 diabetics, and 34 type 2 diabetics with end-stage renal disease, all of whom had been referred for kidney transplantation.
The 278 patients and 67 healthy control subjects underwent evoked tests (changes in heart rate with deep breathing and Valsalva maneuver) and 24-hour heart rate variability Holter monitoring (time and frequency domains). Five patients had sudden cardiac deaths during the study.
Data showed that end-stage renal disease patients, particularly diabetics, had compromised autonomic function. The standard deviation of all R-to-R intervals for the electrocardiogram recording (< 50 minutes in 60% of the deceased patients), a 24-hour heart rate variability time domain measure, holds the promise of identifying patients at increased risk for death. Exercise was identified as a factor associated with better autonomic function. Examining relationships between 24-hour heart rate variability and characteristics of patients who succumb to death could make quantification of the mortality risk for individual pretransplant end-stage renal disease patients possible, much as it has in other populations. The data from this study may also make it possible to design interventions, such as exercise, aimed at reducing mortality risk.
[show abstract][hide abstract] ABSTRACT: The UT Memphis group has made a number of important contributions to the field of PTX, including: 1) pioneering studies on the effects of PTX on autonomic neuropathy, 2) comprehensive reports dealing with quality of life after PTX, 3) seminal studies on the metabolic effects of PTX with portal venous delivery of insulin, 4) refining and perfecting a novel technique of PTX with portal venous drainage of insulin and primary enteric drainage of the exocrine secretions, 5) describing a safe outpatient percutaneous technique of pancreas allograft biopsy, 6) developing the use of glucose tolerance for rejection surveillance, and 7) managing PTX patients with biopsy-directed immunosuppression and no anti-lymphocyte induction therapy. The P-E technique has the potential to become the standard of care in the near future because it is more physiologic, normalizes carbohydrate and lipid metabolism, and minimizes complications attributed to the transplant procedure. In addition, we have been actively involved in studying new immunosuppressive regimens in order to improve and simplify the care of the PTX recipient. We believe that PTX will remain an important treatment option for IDDM until other strategies are developed that can provide equal glycemic control with less or no immunosuppression and less overall morbidity.