Vaccination practices in End Stage Renal Failure and Renal Transplantation; Review of current guidelines and recommendations

Due to the increased burden of infectious complications following solid organ transplantation, vaccination against common pathogens is a hugely important area of discussion and application in clinical practice. Reduction in infectious complications will help to reduce morbidity and mortality post-transplantation. Immunisation history is invaluable in the work-up of potential recipients. Knowledge of the available vaccines and their use in transplant recipients, donors and healthcare providers is vital in the delivery of quality care to transplant recipients. This article will serve as an aide-memoire to transplant physicians and health care professionals involved in managing transplant recipients as it provides an overview of different types of vaccines, timing of vaccination, vaccines contraindicated post solid organ transplantation and travel vaccines.

Evaluation of 3-D Printed Immobilisation Shells for Head and Neck IMRT

This paper presents the preclinical evaluation of a novel immobilization system for patients undergoing external beam radiation treatment of head and neck tumors. An immobilization mask is manufactured directly from a 3-D model, built using the CT data routinely acquired for treatment planning so there is no need to take plaster of Paris moulds. Research suggests that many patients find the mould room visit distressing and so rapid prototyping could potentially improve the overall patient experience. Evaluation of a computer model of the immobilization system using an anthropomorphic phantom shows that >99% of vertices are within a tolerance of ±0.2 mm. Hausdorff distance was used to analyze CT slices obtained by rescanning the phantom with a printed mask in position. These results show that for >80% of the slices the median “worse-case” tolerance is approximately 4 mm. These measurements suggest that printed masks can achieve similar levels of immobilization to those of systems currently in clinical use.

Content of nursing discharge notes: Associations with patient and transfer characteristics

Background: In situations of care transfer of older people from hospital to home care at discharge, exchanging relevant and necessary information about the patient’s health status and individual needs are of importance to ensure continuity and appropriate nursing follow-up care. Objective: The objectives of the study were to: 1) examine the content of nurses’ discharge notes of older patients’ discharged from hospital to home care, and 2) investigate the association between the content of discharge notes and characteristics of patient and transfer. Methods: The nursing discharge notes of 70 older patients admitted to a geriatric unit and a general medicine ward at a local hospital in central Norway were analysed. The discharge notes were structured in accordance with the Well-being, Integrity, Prevention, and Safety (VIPS) model. Mean, standard deviations, and independent sample t-tests were performed to show and examine differences in use of VIPS keywords in relation to patient and transfer characteristics. To examine if use of VIPS keywords could be predicted by patient and transfer characteristics, linear multiple regression analyses were used. Results: Significant differences for mean scores on used VIPS keywords in the discharge note were found for gender, age, and medical department facility. While gender and medical department facility were significant predictors of mental related keywords in the discharge note, medical department facility was a significant predictor of physical related keywords. Conclusions: The result of this study indicate that documentation of patient status in the nursing discharge note of older patients transferred from hospital to home care is incomplete and are influenced by patient and transfer characteristics. In order to ensure continuity and appropriate nursing follow-up care, we emphasize the need for a more comprehensive approach to older patients, and that this must be reflected in the nursing discharge note.

Processes through Which the Grandparents of a Child with Severe Motor and Intellectual Disabilities (SMID) May Become Involved in Raising the Child

In Japan, it is common practice to involve grandparents in the care of children with severe motor and intellectual disabilities (SMID), as it may be difficult for nuclear families to handle such children by themselves. This study aimed to explore and describe the process through which the grandparents of children with SMID may be involved in their upbringing. Data were obtained via semi-structured interviews with 13 grandparents who had a grandchild with SMID. The collected data were examined using Yasuhito Kinoshita’s modified grounded theory approach. Altogether, 11 categories were identified from 29 themes. The results revealed two broad patterns concerning the nature of the grandparents’ involvement and their definition of grandparenthood in the context of raising a grandchild with SMID. In one process, grandparents supported the child’s family. They also learned to relate to the child and their family, despite experiencing a lack of responsiveness from the child initially. This ultimately resulted in them being inspired by their grandchild. In the other process, the grandparents left the care of their grandchild to the child’s family and chose to monitor the child’s welfare indirectly. In both the processes, the level of involvement was determined by the extent to which the family chose to ask grandparents for help. The study’s findings can be used to identify the kind of support that grandparents of children with SMID require while highlighting the role of considering the needs and intentions of the children’s families.

Human leukocyte antigen typing and crossmatch:A comprehensive review

Renal transplantation remains the best option for patients suffering from end stage renal disease(ESRD).Given the worldwide shortage of organs and growing population of patients with ESRD,those waitlisted for a transplant is ever expanding.Contemporary crossmatch methods and human leukocyte antigen(HLA) typing play a pivotal role in improving organ allocation and afford better matches to recipients.Understanding crossmatch as well as HLA typing for renal transplantation and applying it in clinical practice is the key step to achieve a successful outcome.Interpretation of crossmatch results can be quite challenging where clinicians have not had formal training in applied transplant immunology.This review aims to provide a worked example using a clinical vignette.Furthermore,each technique is discussed in detail with its pros and cons.The index case is that of a young male with ESRD secondary to Lupus nephritis.He is offered a deceased donor kidney with a 1-0-0 mismatch.His complement dependent cytotoxicity(CDC) crossmatch reported positive for B lymphocyte,but flow cytometry crossmatch(FCXM) was reported negative for both B and T lymphocytes.Luminex-SAB(single antigen bead) did not identify any donor specific antibodies(DSA).He never had a blood transfusion.The positive CDCcrossmatch result is not concordant with DSA status.These implausible results are due to underlying lupus erythematosus,leading to false-positive B-lymphocyte crossmatch as a result of binding immune complexes to Fc-receptors.False positive report of CDC crossmatch can be caused by the underlying autoimmune diseases such as lupus erythematosus,that may lead to inadvertent refusal of adequate kidney grafts.Detailed study of DSA by molecular technique would prevent wrong exclusion of such donors.Based on these investigations this patient is deemed to have "standard immunological risk" for renal transplantation.

Thrombotic microangiopathy after renal transplantation: Current insights in de novo and recurrent disease

Thrombotic microangiopathy(TMA) is one of the most devastating sequalae of kidney transplantation. A number of published articles have covered either de novo or recurrent TMA in an isolated manner. We have, hereby, in this article endeavored to address both types of TMA in a comparative mode. We appreciate that de novo TMA is more common and its prognosis is poorer than recurrent TMA; the latter has a genetic background, with mutations that impact disease behavior and, consequently, allograft and patient survival. Post-transplant TMA can occur as a recurrence of the disease involving the native kidney or as de novo disease with no evidence of previous involvement before transplant. While atypical hemolytic uremic syndrome is a rare disease that results from complement dysregulation with alternative pathway overactivity, de novo TMA is a heterogenous set of various etiologies and constitutes the vast majority of post-transplant TMA cases. Management of both diseases varies from simple maneuvers, e.g., plasmapheresis, drug withdrawal or dose modification, to lifelong complement blockade, which is rather costly. Careful donor selection and proper recipient preparation, including complete genetic screening, would be a pragmatic approach. Novel therapies, e.g., purified products of the deficient genes, though promising in theory, are not yet of proven value.

Utility of central venous pressure measurement in renal transplantation: Is it evidence based?

Adequate intravenous fluid therapy is essential in renal transplant recipients to ensure a good allograft perfusion. Central venous pressure(CVP) has been cons-idered the corners-tone to guide the fluid therapy for decades; it was the only available simple tool worldwide. However, the revolutionary advances in assessing the dynamic preload variables together with the availability of new equipment to precisely measure the effect of intravenous fluids on the cardiac output had created a question mark on the future role of CVP. Des-pite the critical role of fluid therapy in the field of tra-nsplantation. There are only a few clinical studies that compared the CVP guided fluid therapy with the other modern techniques and their relation to the outcome in renal transplantation. Our work sheds some light on the available published data in renal transplantation, together with data from other disciplines evaluating the utility of central venous pressure measurement. Although lager well-designed studies are still required to consolidate the role of new techniques in the field of renal transplantation, we can confidently declare that the new techniques have the advantages of providing more accurate haemodynamic assessment, which results in a better patient outcome.

Recurrence of primary glomerulonephritis:Review of the current evidence

In view of the availability of new immunosuppression strategies,the recurrence of allograft glomerulonephritis(GN) are reported to be increasing with time post transplantation.Recent advances in understanding the pathogenesis of the GN recurrent disease provided a better chance to develop new strategies to deal with the GN recurrence.Recurrent GN diseases manifest with a variable course,stubborn behavior,and poor response to therapy.Some types of GN lead to rapid decline of kidney function resulting in a frustrating return to maintenance dialysis.This subgroup of aggressive diseases actually requires intensive efforts to ascertain their pathogenesis so that strategy could be implemented for better allograft survival.Epidemiology of native glomerulonephritis as the cause of end-stage renal failure and subsequent recurrence of individual glomerulonephritis after renal transplantation was evaluated using data from various registries,and pathogenesis of individual glomerulonephritis is discussed.The following review is aimed to define current protocols of the recurrent primary glomerulonephritis therapy.

Post-transplantation lymphoproliferative disorders:Current concepts and future therapeutic approaches

Transplant recipients are vulnerable to a higher risk of malignancy after solid organ transplantation and allogeneic hematopoietic stem-cell transplant.Posttransplant lymphoproliferative disorders(PTLD)include a wide spectrum of diseases ranging from benign proliferation of lymphoid tissues to frank malignancy with aggressive behavior.Two main risk factors of PTLD are:Firstly,the cumulative immunosuppressive burden,and secondly,the oncogenic impact of the Epstein-Barr virus.The latter is a key pathognomonic driver of PTLD evolution.Over the last two decades,a considerable progress has been made in diagnosis and therapy of PTLD.The treatment of PTLD includes reduction of immunosuppression,rituximab therapy,either isolated or in combination with other chemotherapeutic agents,adoptive therapy,surgical intervention,antiviral therapy and radiotherapy.In this review we shall discuss the prevalence,clinical clues,prophylactic measures as well as the current and future therapeutic strategies of this devastating disorder.

Pancreatic transplantation: Brief review of the current evidence

Kidney transplantation is the treatment of choice for management of end-stage renal disease.However,in diabetic patients,the underlying metabolic disturbance will persist and even may get worse after isolated kidney transplantation.Pancreatic transplantation in humans was first introduced in 1966.The initial outcome was disappointing.However,this was changed after the improvement of surgical techniques together with better patient selection and the availability of potent and better-tolerated immune-suppression like cyclosporine and induction antibodies.Combined kidney and pancreas transplantation will not only solve the problem of organ failure,but it will also stabilise or even reverse the metabolic complications of diabetes.Combined kidney and pancreas transplantation have the best long term outcome in diabetic cases with renal failure.Nevertheless,at the cost of an initial increase in morbidity and risk of mortality.Other transplantation options include pancreas after kidney transplantation and islet cell transplantation.We aim by this work to explore various options which can be offered to a diabetic patient with advanced chronic kidney disease.Our work will provide a simplified,yet up-to-date information regarding the different management options for those diabetic chronic kidney failure patients.

Complement-mediated renal diseases after kidney transplantation-current diagnostic and therapeutic options in de novo and recurrent diseases

For decades, kidney diseases related to inappropriate complement activity, such as atypical hemolytic uremic syndrome and C3 glomerulopathy(a subtype of membranoproliferative glomerulonephritis), have mostly been complicated by worsened prognoses and rapid progression to end-stage renal failure. Alternative complement pathway dysregulation, whether congenital or acquired, is well-recognized as the main driver of the disease process in these patients. The list of triggers include: surgery, infection, immunologic factors, pregnancy and medications. The advent of complement activation blockade, however, revolutionized the clinical course and outcome of these diseases, rendering transplantation a viable option for patients who were previously considered as non-transplantable cases.Several less-costly therapeutic lines and likely better efficacy and safety profiles are currently underway. In view of the challenging nature of diagnosing these diseases and the long-term cost implications, a multidisciplinary approach including the nephrologist, renal pathologist and the genetic laboratory is required to help improve overall care of these patients and draw the optimum therapeutic plan.

Journey of a patient with scleroderma from renal failure up to kidney transplantation

The increased awareness of systemic sclerosis(SS)and its pathogenetic background made the management of this disease more amenable than previously thought.However,scleroderma renal crisis(SRC)is a rarely seen as an associated disorder that may involve 2%-15%of SS patients.Patients presented with earlier,rapidly progressing,diffuse cutaneous SS disease,mostly in the first 3-5 years after non-Raynaud clinical manifestations,are more vulnerable to develop SRC.SRC comprises a collection of acute,mostly symptomatic rise in blood pressure,elevation in serum creatinine concentrations,oliguria and thrombotic microangiopathy in almost 50%of cases.The advent of the antihypertensive angiotensin converting enzyme inhibitors in 1980 was associated with significant improvement in SRC prognosis.In a scleroderma patient maintained on regular dialysis;every effort should be exerted to declare any possible evidence of renal recovery.A given period of almost two years has been suggested prior to proceeding in a kidney transplant(KTx).Of note,SS patients on dialysis have the highest opportunity of renal recovery and withdrawal from dialysis as compared to other causes of end-stage renal disease(ESRD).KTx that is the best well-known therapeutic option for ESRD patients can also be offered to SS patients.Compared to other primary renal diseases,SS-related ESRD was considered for a long period of poor patient and allograft survivals.Pulmonary involvement in an SS patient is considered a strong post-transplant independent risk factor of death.Recurrence of SRC after transplantation has been observed in some patients.However,an excellent post-transplant patient and graft outcome have been recently reported.Consequently,the absence of extrarenal manifestations in an SS-induced ESRD patient can be accepted as a robust indicator for a successful KTx.

A description of resilience for Norwegian home-living chronically ill oldest older persons

Background: Despite worsening health the chronically ill oldest older persons have expressed feelings of inner strength, which can be understood as resilience. The objective was to describe and compare the characteristics of resilience in two different age groups of chronically ill oldest older persons living at home and who needed help from home nursing care. Design: Cross-sectional design was used to describe and compare the resilience qualities between the two age groups. Methods: The inclusion criteria were 80 years or older, living at home with chronic disease, receiving help from home nursing care, and with the capacity to be interviewed. A sample of 120 oldest older women (n = 79) and men (n = 41) separated in two age groups, aged 80- 89 and 90+ years, participated in the study. Resilience characteristics were measured by Resilience Scale. Results: The whole group of oldest older people was vulnerable in relation to the characteristics of perseverance, self-reliance, and existential aloneness. Despite reduced physical health they reported a meaningful life, and equanimity. Even if there were no significant differences between the age groups among the oldest older persons in the characteristics of Resilience Scale (RS), in the characteristic of meaning there was a tendency of interaction between age and how much help from home nursing care the participants received. Conclusions: It is important to focus on the individual aging and the risk of developing illness and disabilities rather than focusing on chronologic age. Possessing meaning in life and equanimity may be strengths to meet challenges through illness and growing older.

De novo glomerular diseases after renal transplantation:How is it different from recurrent glomerular diseases?

The glomerular diseases after renal transplantation can occur de novo,i.e.,with no relation to the native kidney disease,or more frequently occur as a recurrence of the original disease in the native kidney.There may not be any difference in clinical features and histological pattern between de novo glomerular disease and recurrence of original glomerular disease.However,structural alterations in transplanted kidney add to dilemma in diagnosis.These changes in architecture of histopathology can happen due to:(1) exposure to the immunosuppression specifically the calcineurin inhibitors(CNI);(2) in vascular and tubulointerstitial alterations as a result of antibody mediated or cellmediated immunological onslaught;(3) post-transplant viral infections;(4) ischemia-reperfusion injury; and(5) hyperfiltration injury.The pathogenesis of the de novo glomerular diseases differs with each type.Stimulation of B-cell clones with subsequent production of the monoclonal Ig G,particularly Ig G3 subtype that has higher affinity to the negatively charged glomerular tissue,is suggested to be included in PGNMID pathogenesis.De novo membranous nephropathy canbe seen after exposure to the cryptogenic podocyte antigens.The role of the toxic effects of CNI including tissue fibrosis and the hemodynamic alterations may be involved in the de novo FSGS pathophysiology.The well-known deleterious effects of HCV infection and its relation to MPGN disease are frequently reported.The new concepts have emerged that demonstrate the role of dysregulation of alternative complement pathway in evolution of MPGN that led to classifying into two subgroups,immune complex mediated MPGN and complement-mediated MPGN.The latter comprises of the dense deposit disease and the C3 GN disease.De novo C3 disease is rather rare.Prognosis of de novo diseases varies with each type and their management continues to be empirical to a large extent.

Early urological complications after kidney transplantation: An overview

Urological complications, especially urine leaks, remain the most common type of surgical complication in the early post-transplant period. Despite major advances in the field of transplantation, a small minority of kidney transplants are still being lost due to urological problems. Many of these complications can be traced back to the time of retrieval and implantation. Serial ultrasound examination of the transplanted graft in the early post-operative period is of key importance for early detection. The prognosis is generally excellent if recognized and managed in a timely fashion. The purpose of this narrative review is to discuss the different presentations, compare various ureterovesical anastomosis techniques and provide a basic overview for the management of post-transplant urological complications.

“Contrast nephropathy” in renal transplantation:Is it real?

The risk of contrast-induced nephropathy(CIN) in renal transplant recipients is increased in diabetics, patients with impaired basal kidney function, patients in shock, patients presenting with acute emergency and in old age recipients. Approximately one-third of all hospitalized patients with acute kidney injury is attributed to CIN. In the United States, it is the third leading cause of hospital-acquired renal failure. Therefore, efforts should be directed to minimize CIN-related morbidity and mortality as well as to shorten hospital stay. While the role of peri-procedural prophylactic hydration with saline is unequivocal; the use of acetyl cysteine is not based on robust evidence. The utility of theophylline, aminophylline, calcium channel blockers, natriuretic peptide, and diuretics does not have proven role in attenuating CIN incidence. We aim to analyze the evidence for using various protocols in published literature to limit CIN-associated morbidity and mortality, particularly during surveillance of the renal allograft survival.

Smoking in Renal Transplantation; Facts Beyond Myth

Smoking is one of the preventable leading causes of death worldwide. Most of the studies focused on the association between smoking and cardiovascular disease, pulmonary diseases, malignancy and death. However, the direct effect of smoking on the renal system was undermind. There are emerging evidence correlating tobacco use with pathological changes in the normal kidneys. The effect is more obvious on the renal allograft most probably due to the chronic immune suppression status and the metabolic effect of the drugs. Several studies have documented a deleterious effect of smoking on the renal transplant recipients. Smoking was associated with lowering patient and graft survival. Smoking cessation proved to improve graft survival and to a lesser extent recipient survival. Even receiving a renal transplant from a smoker donor increases the risk of death for the recipient and carries a poorer graft survival compared to non-smoking donors. Most of the studies investigating the effect of smoking were based on self-reporting questioners, which may be misleading due to poor recall or the desire to give socially acceptable answers. This made the need of a reliable biomarker of ultimate importance. Cotinine was proposed as a promising biomarker that may help to provide objective evidence regarding the status of smoking and the dose of nicotine exposure, yet there are still some limitations of its use. The aim of this work is to review the current evidence to improve our understanding of this critical topic. Indeed, this will help to guide better-designed studies in the future.

培训初级医疗临床工作者给予患者适应性改变多种生活行为的咨询：整体随机试验

目的以患者自我报告4项健康相关行为（吸烟、饮酒、锻炼及饮食）改善的比例为评估点，评估针对初级医疗临床工作者开展的“行为改变咨询”培训的效果。