Paul J.M. van der Boog

An online lifestyle diary with a persuasive computer assistant providing feedback on self-management

In accordance with the global trend, in The Netherlands approximately 45% of the population is overweight. Existing studies show that patient self-management can reduce these figures, but medical non-adherence is a persistent problem. eHealth can potentially increase adherence to self-management. Consequently, we designed a persuasive computer assistant and evaluated its influence on self-management, i.e., the use of an online lifestyle diary called DieetInzicht.nl. The assistant is represented by an animated iCat, which shows different facial expressions and provides cooperative feedback following principles from the motivational interviewing method. We conducted a randomized controlled trial with 118 overweight people over a period of four weeks and studied the difference between diary use with and without computer assistant feedback. Results show that the computer assistant contributed to filling in the diary more frequently, reduced the decline in motivation to perform self-management, lowered the (reported) BMI, and improved the ease of use. Furthermore, diary use increased knowledge of maintaining a healthy lifestyle. Finally, personal characteristics, i.e., locus of control, vocabulary, computer experience, age, gender, education level and initial BMI, explained the variance in the diary use and its outcome. Of the 118 participants 35 filled in the closing survey, covering motivation, BMI, lifestyle knowledge and ease of use, which implies that the findings based on these results are mainly representative for motivated participants. In general, this study shows that the Dieetinzicht eHealth service, including a personal computer assistant, is likely to support motivated overweight people and lifestyle related diseases to get a better insight in and adhere to their self-management.

FcαRI/CD89 Circulates in Human Serum Covalently Linked to IgA in a Polymeric State

The FcR for IgA CD89/FcαRI, is a type I receptor glycoprotein, expressed on myeloid cells, with important immune effector functions. In vitro CD89 can be released from CD89-expressing cells upon activation. Little information is available on the existence of this soluble molecule in vivo. Using specific and sensitive ELISA techniques (detection limit 50 pg/ml), we were not able to detect circulating CD89 in human sera. However, using Western blotting, a 30-kDa soluble CD89 molecule was demonstrated in both serum and plasma. Moreover, using a specific semiquantitative dot-blot system, we found CD89 in all human sera tested (mean concentration 1900 ng/ml). Size fractionation of human serum using gel filtration chromatography showed that the CD89 molecule was predominantly present in larger molecular mass fractions. Direct complexes between IgA and CD89 were demonstrated by anti-IgA affinity purification, and when analyzed under nonreducing conditions appeared to be covalently linked. Size fractionation of affinity-purified IgA showed the presence of soluble CD89 only in the high molecular mass fractions of IgA, but not in monomeric IgA. High molecular mass complexes of CD89-IgA could be distinguished from J chain containing dimeric IgA. These data show that CD89 circulates in complex with IgA, and suggest that CD89 might contribute to the formation of polymeric serum IgA.

An empowerment-based approach to developing innovative e-health tools for self-management

E-health is seen as an important technological tool in achieving self-management; however, there is little evidence of how effective e-health is for self-management. Example tools remain experimental and there is limited knowledge yet about the design, use, and effects of this class of tools. By way of introducing a new view on the development of e-health tools dedicated to self-management we aim to contribute to the discussion for further research in this area. Our assumption is that patient empowerment is an important mechanism of e-health self-management and we suggest incorporating it within the development of self-management tools. Important components of empowerment selected from literature are: communication, education and health literacy, information, self-care, decision aids and contact with fellow patients. All components require skills of both patients and the physicians. In this discussion paper we propose how the required skills can be used to specify effective self-management tools.

Reduced quality of life in living kidney donors: association with fatigue, societal participation and pre-donation variables

Health related quality of life (HRQoL) of living kidney donors on average is good, but some donors experience a low HRQoL after donation. This study assessed the prevalence of reduced HRQoL and explored associations with pre‐ and post‐donation variables. 316 donors (response rate 74%) who donated a kidney between 1997 and 2009 filled in a questionnaire. HRQoL was measured using the Short‐Form 36; fatigue using the Multidimensional Fatigue Inventory; societal participation using the Utrecht Scale for Evaluation of Rehabilitation‐Participation. Donors on average had better HRQoL than the general population. However, 12% had a reduced physical (PCS) and 18% a reduced mental (MCS) HRQoL. Donors with reduced HRQoL reported greater fatigue (P < 0.01), lower societal participation (P < 0.01) and showed a trend towards statistical significance in experiencing more donor–recipient relationship changes (P = 0.07). Prior to donation, donors with reduced PCS had a higher BMI (P < 0.05) and more often smoked (P < 0.05). Donors with reduced MCS had higher expectations (P < 0.05). Reduced HRQoL is associated with higher BMI, smoking and higher expectations prior to donation. These results may be used to develop a screening instrument to select donors at high risk for reduced HRQoL.

Increased Risk of Squamous-Cell Carcinoma in Simultaneous Pancreas Kidney Transplant Recipients Compared with Kidney Transplant Recipients

The purpose of this study was to ascertain the risk of non-melanocytic skin cancer (NMSC) in simultaneous pancreas kidney transplant recipients (SPKTRs) compared with kidney transplant recipients (KTRs) in relation to other potential risk factors of skin cancer. In a cohort study, 208 SPKTRs were compared with 1,111 KTRs who were transplanted during the same time period. The effects of age, sex, country of origin, time period after transplantation, HLA matching, immunosuppressive regimen, and rejection treatments on the risk of NMSC were investigated in multivariable Coxs proportional hazard models. In SPKTRs, the incidence of NMSC increased from 19 to 36%, respectively, 10 and 15 years after transplantation, which was significantly higher compared with that in KTRs (6 and 10%, respectively). After adjustment for age and sex, SPKTRs had a 6.2 (3.0-12.8) increased risk of squamous-cell carcinoma (SCC) compared with KTRs. An additional adjustment for maintenance immunosuppression decreased the hazard ratio to 3.1 (1.3, 7.2), which indicates partial confounding by the immunosuppressive regimen. Adjustment for induction and rejection therapy or HLA mismatching did not change the hazard ratio significantly. SPKTRs have an increased risk of SCC compared with KTRs, despite partial confounding by the immunosuppressive regimen.

Variation in Leukocyte Subset Concentrations Affects Calcineurin Activity Measurement: Implications for Pharmacodynamic Monitoring Strategies

BACKGROUND In renal transplantation patients, therapeutic drug monitoring of the calcineurin (CN) inhibitor cyclosporin A (CsA) is mandatory because of the drugs narrow therapeutic index. Pharmacodynamic monitoring of CN inhibition therapy could provide a tool to define and maintain the therapeutic efficacy of CsA therapy. We investigated the effect of variation in cell counts of leukocyte subsets on leukocyte CN activity measurement in renal transplant recipients. METHODS We measured leukocyte CN activity, whole blood CsA concentrations, and leukocyte subset cell counts in 25 renal transplant recipients. Blood was collected before graft implantation and CsA therapy, 1 day before transplantation when CsA therapy was already started, and 5 days after transplantation. Monocyte, granulocyte, CD4+ T-cell, CD8+ T-cell, B-cell, and natural killer-cell CN activities and CsA inhibition sensitivities were determined in vitro by a spectrophotometric CN assay. RESULTS Leukocyte CN activity was inhibited after drug intake. Inter- and intrapatient variation in leukocyte subset cell counts resulted in variation of sample composition. The mean (SD) CN activity varied among leukocyte cell subsets, ranging from 650 (230) to 166 (26) pmol/min/10(6) cells for monocytes and CD4+ T cells, respectively. CsA half maximal inhibitory concentration (IC(50)) values ranged from 15 to 78 microg/L for monocytes and B cells, respectively. CONCLUSION Inter- and intraindividual leukocyte subset cell count variation can affect measured CN activity independent of CsA concentration. Cell-specific activity and drug sensitivity should be considered for sample validation to optimize method specificity when pharmacodynamic monitoring strategies are applied in a clinical setting.

Pancreas transplantation: advantages of both enteric and bladder drainage combined in a two-step approach.

Abstract: Background: Although there is a tendency to perform enteric drainage of pancreas transplants in simultaneous pancreas–kidney (SPK) transplantation, bladder drainage is still preferable in pancreas transplantation alone (PTA) or after a previous kidney transplantation (PAK). Our hypothesis was that enteric conversion of a bladder drained pancreas is an effective and safe procedure. We studied the complication rate and physiological effects of enteric conversion in patients with primary bladder‐drained SPK transplantation.

Decision making around living and deceased donor kidney transplantation: a qualitative study exploring the importance of expected relationship changes

BackgroundLimited data exist on the impact of living kidney donation on the donor-recipient relationship. Purpose of this study was to explore motivations to donate or accept a (living donor) kidney, whether expected relationship changes influence decision making and whether relationship changes are actually experienced.MethodsWe conducted 6 focus groups in 47 of 114 invited individuals (41%), asking retrospectively about motivations and decision making around transplantation. We used qualitative and quantitative methods to analyze the focus group transcripts.ResultsMost deceased donor kidney recipients had a potential living donor available which they refused or did not want. They mostly waited for a deceased donor because of concern for the donor’s health (75%). They more often expected negative relationship changes than living donor kidney recipients (75% vs. 27%, p = 0.01) who also expected positive changes. Living donor kidney recipients mostly accepted the kidney to improve their own quality of life (47%). Donors mostly donated a kidney because transplantation would make the recipient less dependent (25%). After transplantation both positive and negative relationship changes are experienced.ConclusionExpected relationship changes and concerns about the donor’s health lead some kidney patients to wait for a deceased donor, despite having a potential living donor available. Further research is needed to assess whether this concerns a selected group.

Perceived Barriers and Support Strategies for Reducing Sodium Intake in Patients with Chronic Kidney Disease: a Qualitative Study

BackgroundReducing sodium intake can prevent cardiovascular complications and further decline of kidney function in patients with chronic kidney disease. However, the vast majority of patients fail to reach an adequate sodium intake, and little is known about why they do not succeed.PurposeThis study aims to identify perceived barriers and support strategies for reducing sodium intake among both patients with chronic kidney disease and health-care professionals.MethodA purposive sample of 25 patients and 23 health-care professionals from 4 Dutch medical centers attended 8 focus groups. Transcripts were analyzed thematically and afterwards organized according to the phases of behavior change of self-regulation theory.ResultsMultiple themes emerged across different phases of behavior change, including the patients’ lack of practical knowledge and intrinsic motivation, the maladaptive illness perceptions and refusal skills, the lack of social support and feedback regarding disease progression and sodium intake, and the availability of low-sodium foods.ConclusionsThe results indicate the need for the implementation of support strategies that target specific needs of patients across the whole process of changing and maintaining a low-sodium diet. Special attention should be paid to supporting patients to set sodium-related goals, strengthening intrinsic motivation, providing comprehensive and practical information (e.g., about hidden salt in products), increasing social support, stimulating the self-monitoring of sodium intake and disease progression, and building a supportive patient–professional relationship that encompasses shared decision making and coaching. Moreover, global programs should be implemented to reduce sodium levels in processed foods, introduce sodium-related product labels, and increase consumer awareness.

Pancreas-kidney transplantations with primary bladder drainage followed by enteric conversion: graft survival and outcomes.

Background. In the Leiden University Medical Centre, a two-step approach is routinely used in simultaneous pancreas-kidney (SPK) transplantations: primary bladder drainage (BD) followed by elective enteric conversion. The rationale for this approach is to prevent the short-term disadvantages of primary enteric drainage (intra-abdominal abscesses, pancreas graft loss) and the long-term urological complications related to bladder drainage. Aim of the present study is to evaluate survival and (urological) complications of this approach compared to enteric drainage (ED). Methods. Patient records of all 98 SPK transplantations in the period 1997–2004 were reviewed for complications during the initial hospitalization until 30 days after discharge, and to assess urological complications and graft survival until the last hospital visit. Median duration of follow-up was 4.3 years for pancreas graft survival, 4.7 years for kidney graft survival, and 4.8 years for patient survival. Results. Patient survival was significantly better in BD patients than in ED patients (&khgr;2=9.89 P<0.01). Pancreas graft survival was also better in BD patients after adjustment for the longer pancreas warm ischemia time in BD patients (P=0.05). The survival rates in our patient population seem higher than reported by the International Pancreas Transplant Registry, particularly in BD patients. Urological complications occurred in nine BD patients (10.3%), comparable to the rates reported for enteric-drained grafts. Conclusions. This two-step approach of SPK transplantation results in excellent survival rates, with urological complication rates comparable to those reported for enteric-drained grafts, and may thus be viewed as a safe and effective procedure of SPK transplantation.