Alvin Ho-ting Li

Fracture risk in kidney transplant recipients: a systematic review.

Background Fractures in men and women after kidney transplantation are associated with morbidity (including acute and chronic pain), mortality, and high economic costs. Methods We systematically reviewed cohort studies that provided estimates on incidence and risk factors for fracture in kidney transplant recipients. We abstracted data in duplicate and assessed the methodological quality of each study on a 17-point scale (17 representing the highest quality). Results We screened 2715 articles, reviewed 81, and included 10 studies totaling 262,678 recipients (study mean, 26,268 recipients; range, 61–77,430). The average follow-up ranged from 1.7 to 5.3 years. The study quality scores ranged from 8 to 13. Fracture sites varied by study resulting in a highly variable incidence rate ranging from 3.3 to 99.6 fractures per 1000 person-years. Similarly, the 5-year cumulative incidence for fracture varied ranging from 0.85% to 27%. Common factors associated with an increased fracture risk were older age, female sex, the presence of diabetes, and receipt of dialysis before transplantation. Other less common but statistically significant risk factors were a previous history of fracture and receipt of a kidney from a deceased (vs. living) donor. Conclusions There is poor consensus on the incidence and risk factors for fractures in kidney transplant recipients. Previous studies vary substantially in quality, fracture definitions, and the characteristics of recipients studied. Future research should clarify fracture incidence and risk, which will inform the design of future prevention trials and guide prognostication.

Systematic Search and Review Procedures: Results of the International Collaboration on Mild Traumatic Brain Injury Prognosis

OBJECTIVES To update the last best-evidence synthesis conducted by the World Health Organization Collaborating Centre for Neurotrauma, Prevention, Management and Rehabilitation in 2002; and to describe the course, identify prognostic factors, determine long-term sequelae, identify effects of interventions for mild traumatic brain injury (MTBI), identify knowledge gaps in the literature, and make recommendations for future research. DATA SOURCES MEDLINE, Embase, PsycINFO, Cumulative Index to Nursing and Allied Health, and SPORTDiscus were searched between 2001 and 2012. Inclusion criteria included published peer-reviewed articles in English and 5 other languages. References were also identified from relevant reviews and meta-analyses and the bibliographies of eligible articles. STUDY SELECTION Controlled trials and cohort and case-control studies were selected according to predefined inclusion/exclusion criteria. Studies had to have at least 30 MTBI cases and assess outcomes relevant to prognosis after MTBI. DATA EXTRACTION Eligible studies were critically appraised using modified Scottish Intercollegiate Guidelines Network (SIGN) criteria. Two reviewers independently reviewed each study and extracted data from accepted articles (ie, with a low risk of bias) into evidence tables. DATA SYNTHESIS The evidence was synthesized qualitatively according to modified SIGN criteria and prioritized according to design as exploratory or confirmatory. The evidence was organized into separate articles according to population (eg, adults, children, and athletes) and outcomes (eg, risk of dementia after MTBI). CONCLUSIONS After 77,914 records were screened, 299 articles were eligible and reviewed. Of these, 101 (34%) were accepted as scientifically admissible and form the basis of our findings, which are organized into 10 articles in this supplement. These reviews present the best available evidence on MTBI prognosis, but more research is needed.

The Risk of Cardiovascular Disease Is Not Increasing Over Time Despite Aging and Higher Comorbidity Burden of Kidney Transplant Recipients

Background Cardiovascular death remains the leading cause of mortality in kidney transplant recipients. Cardiovascular events are associated with significant morbidity. However, current trends in cardiovascular events after kidney transplantation are poorly understood. Methods We conducted a retrospective study using healthcare databases in Ontario, Canada, to determine whether the incidence of cardiovascular events after kidney transplantation has changed from 1994 to 2009. Our primary endpoint was a 3-year composite outcome of posttransplant death or major cardiovascular event (myocardial infarction, coronary angioplasty, coronary artery bypass graft surgery, stroke). Results Recipients (n = 4954) were older and had more baseline comorbidity in recent years. A total of 445 recipients (9.0%) died or experienced a major cardiovascular event within 3 years of transplantation. There was no significant change in the incidence of the composite outcome or death-censored cardiovascular events over time (P = 0.41 and 0.92, respectively). After adjusting for age, sex, and comorbidities, the risk of death or major cardiovascular event steadily declined across the years of transplant (2006-2009 adjusted hazard ratio, 0.70; P = 0.009; referent 1994-1997). When recipients were matched on age, sex, and date of cohort entry to members of the general population and to the chronic kidney disease population, the risk was lowest in the general population and highest in the chronic kidney disease population. Conclusion Despite transplant centers accepting recipients who are older with more comorbidities in recent years, the 3-year cumulative incidence of death or major cardiovascular event has remained stable over time.

Adolescent classroom education on knowledge and attitudes about deceased organ donation: A systematic review

In many countries, adolescents can choose to register a deceased organ donation wish when they apply for a drivers license. They often receive education about deceased organ donation in order to make an informed choice. The objective of this review was to describe the effectiveness of school‐based educational programs on deceased organ donation among adolescents. We reviewed any study of adolescent students receiving a school‐based educational program on deceased organ donation. The outcomes were knowledge, attitudes, intent to register a preference toward deceased organ donation, and whether such education fostered family discussions about organ donation. Fifteen studies were summarized from nine countries, of which six were randomized controlled trials. Most educational programs consisted of one or two classroom sessions. The methods employed in five studies received a high‐quality rating. Educational programs increased knowledge in 10 studies, and attitudes in five studies, with variable effects on intent to affirmative registration. Seven studies reported success in promoting family discussions. Adolescent classroom education is a promising strategy to improve knowledge about deceased organ donation and appears to increase public support for donation. Subjecting these programs to additional evaluation will clarify their impact on affirmative donor registration and realized donations.

Early Hospital Readmissions After Transplantation: Burden, Causes, and Consequences.

Background Solid organ transplantation is the preferred treatment for patients with end-stage organ failure. Although much progress has been made over the past decade, some patients still require early readmission after their initial hospital discharge. Early hospital readmission is an important metric for health care quality. It is often measured in nontransplant medical and surgical conditions but has only recently been applied to organ transplantation. Methods We performed a structured MEDLINE search to retrieve, review, and summarize original studies on the incidence, risk factors, outcomes, and prevention of early hospital readmissions after kidney, liver, and kidney-pancreas transplantation. Early hospital readmission was defined as readmission to hospital within 30 days of discharge from the transplant hospitalization. Results The risk of early readmission varies by organ type, (highest in liver transplants and lowest in kidney transplants). Causes for early hospital readmission are most commonly due to surgical, immunologic, or infectious complications. Risk factors associated with early hospital readmission often reflect pretransplant comorbidity, and many of these factors may not be modifiable. Early hospital readmission is also associated with decreased graft and patient survival. Conclusions Early hospital readmission after transplantation is common and associated with adverse outcomes. The potential for preventing early hospital readmissions and the impact on patient outcomes remain unclear. Current evidence suggests that some, but not all, early hospital readmissions after transplantation may be prevented.

Deceased Organ Donation Registration and Familial Consent among Chinese and South Asians in Ontario, Canada

Objective For various reasons, people of Chinese (China, Hong Kong or Taiwan) and South Asian (Indian subcontinent) ancestry (the two largest ethnic minority groups in Ontario, Canada) may be less likely to register for deceased organ donation than the general public, and their families may be less likely to consent for deceased organ donation at the time of death. Methods We conducted two population-based studies: (1) a cross-sectional study of deceased organ donor registration as of May 2013, and (2) a cohort study of the steps in proceeding with deceased organ donation for patients who died in hospital from October 2008 to December 2012. Results A total of 49 938 of 559 714 Chinese individuals (8.9%) and 47 774 of 374 291 South Asians (12.8%) were registered for deceased organ donation, proportions lower than the general public (2 676 260 of 10 548 249 (25.4%). Among the 168 703 Ontarians who died in a hospital, the families of 33 of 81 Chinese (40.1%; 95% CI: 30.7%-51.6%) and 39 of 72 South Asian individuals (54.2%; 95% CI: 42.7-65.2%) consented for deceased organ donation, proportions lower than the general public (68.3%; 95% CI: 66.4%-70.0%). Conclusions In Ontario, Canada Chinese and South Asian individuals are less likely to register and their families are less likely to consent to deceased organ donation compared to the remaining general public. There is an opportunity to build support for organ and tissue donation in these two large ethnic communities in Canada.

Physician Registration for Deceased Organ Donation

A shortage of organs for transplant has prompted many countries to encourage citizens to register (“opt in”) to donate their organs and tissues when they die.1 However, less than 40% of the public is registered for organ donation in most countries with a registry.1 One common fear is that physicians will not take all measures to save the life of a registered citizen at a time of illness.2 Showing that many physicians are registered for organ donation themselves could help dispel this myth. Although most physicians in surveys support organ donation,3 whether they are actually registered remains unknown.

Improving safety culture in hospitals: Facilitators and barriers to implementation of Systemic Falls Investigative Method (SFIM)

Objective The purpose of this study was to assess the facilitators and barriers to implementation of the Systemic Falls Investigative Method (SFIM) on selected hospital units. Design A cross-sectional explanatory mixed methods design was used to converge results from a standardized safety culture survey with themes that emerged from interviews and focus groups. Findings were organized by six elements of the Ottawa Model of Research Use framework. Setting A geriatric rehabilitation unit of an acute care hospital and a neurological unit of a rehabilitation hospital were selected purposefully due to the high frequency of falls. Participants Hospital staff who took part in: surveys (n = 39), interviews (n = 10) and focus groups (n = 12), and 38 people who were interviewed during falls investigations: fallers, family, unit staff and hospital management. Intervention Implementation of the SFIM to investigate fall occurrences. Main Outcome Measure(s) Percent of positive responses on the Modified Stanford Patient Safety Culture Survey Instrument converged with qualitative themes on facilitators and barriers for intervention implementation. Results Both hospital units had an overall poor safety culture which hindered intervention implementation. Facilitators were hospital accreditation, strong emphasis on patient safety, infrastructure and dedicated champions. Barriers included heavy workloads, lack of time, lack of resources and poor communication. Conclusions Successful implementation of SFIM requires regulatory and organizational support, committed frontline staff and allocation of resources to identify active causes and latent contributing factors to falls. System-wide adjustments show promise for promotion of safety culture in hospitals where falls happen regularly.

ESRD among Immigrants to Ontario, Canada: A Population-Based Study

Background The epidemiology of ESRD requiring maintenance dialysis (ESRD-D) in large, diverse immigrant populations is unclear.Methods We estimated ESRD-D prevalence and incidence among immigrants in Ontario, Canada. Adults residing in Ontario in 2014 were categorized as long-term Canadian residents or immigrants according to administrative health and immigration datasets. We determined ESRD-D prevalence among these adults and calculated age-adjusted prevalence ratios (PRs) comparing immigrants to long-term residents. Among those who immigrated to Ontario between 1991 and 2012, age-adjusted ESRD-D incidence was calculated by world region and country of birth, with immigrants from Western nations as the referent group.Results Among 1,902,394 immigrants and 8,860,283 long-term residents, 1700 (0.09%) and 8909 (0.10%), respectively, presented with ESRD-D. Age-adjusted ESRD-D prevalence was higher among immigrants from sub-Saharan Africa (PR, 2.17; 95% confidence interval [95% CI], 1.84 to 2.57), Latin America and the Caribbean (PR, 2.11; 95% CI, 1.90 to 2.34), South Asia (PR, 1.45; 95% CI, 1.32 to 1.59), and East Asia and the Pacific (PR, 1.34; 95% CI, 1.22 to 1.46). Immigrants from Somalia (PR, 4.18; 95% CI, 3.11 to 5.61), Trinidad and Tobago (PR, 2.88; 95% CI, 2.23 to 3.73), Jamaica (PR, 2.88; 95% CI, 2.40 to 3.44), Sudan (PR, 2.84; 95% CI, 1.53 to 5.27), and Guyana (PR, 2.69; 95% CI, 2.19 to 3.29) had the highest age-adjusted ESRD-D PRs relative to long-term residents. Immigrants from these countries also exhibited higher age-adjusted ESKD-D incidence relative to Western Nations immigrants.Conclusions Among immigrants in Canada, those from sub-Saharan Africa and the Caribbean have the highest ESRD-D risk. Tailored kidney-protective interventions should be developed for these susceptible populations.

Variation in Access to Kidney Transplantation Across Renal Programs in Ontario, Canada

In the United States, kidney transplant rates vary significantly across end‐stage renal disease (ESRD) networks. We conducted a population‐based cohort study to determine whether there was variability in kidney transplant rates across renal programs in a health care system distinct from the United States. We included incident chronic dialysis patients in Ontario, Canada, from 2003 to 2013 and determined the 1‐, 5‐, and 10‐year cumulative incidence of kidney transplantation in 27 regional renal programs (similar to U.S. ESRD networks). We also assessed the cumulative incidence of kidney transplant for “healthy” dialysis patients (aged 18–50 years without diabetes, coronary disease, or malignancy). We calculated standardized transplant ratios (STRs) using a Cox proportional hazards model, adjusting for patient characteristics (maximum possible follow‐up of 11 years). Among 23 022 chronic dialysis patients, the 10‐year cumulative incidence of kidney transplantation ranged from 7.4% (95% confidence interval [CI] 4.8–10.7%) to 31.4% (95% CI 16.5–47.5%) across renal programs. Similar variability was observed in our healthy cohort. STRs ranged from 0.3 (95% CI 0.2–0.5) to 1.5 (95% CI 1.4–1.7) across renal programs. There was significant variation in kidney transplant rates across Ontario renal programs despite patients having access to the same publicly funded health care system.