Rachel C. Forbes

Older candidates for kidney transplantation: Who to refer and what to expect?

The number of older end-stage renal disease patients being referred for kidney transplantation continues to increase. This rise is occurring alongside the continually increasing prevalence of older end-stage renal disease patients. Although older kidney transplant recipients have decreased patient and graft survival compared to younger patients, transplantation in this patient population is pursued due to the survival advantage that it confers over remaining on the deceased donor waiting list. The upper limit of age and the extent of comorbidity and frailty at which transplantation ceases to be advantageous is not known. Transplant physicians are therefore faced with the challenge of determining who among older patients are appropriate candidates for kidney transplantation. This is usually achieved by means of an organ systems-based medical evaluation with particular focus given to cardiovascular health. More recently, global measures of health such as functional status and frailty are increasingly being recognized as potential tools in risk stratifying kidney transplant candidates. For those candidates who are deemed eligible, living donor transplantation should be pursued. This may mean accepting a kidney from an older living donor. In the absence of any living donor, the choice to accept lesser quality kidneys should be made while taking into account the organ shortage and expected waiting times on the deceased donor list. Appropriate counseling of patients should be a cornerstone in the evaluation process and includes a discussion regarding expected outcomes, expected waiting times in the setting of the new Kidney Allocation System, benefits of living donor transplantation and the acceptance of lesser quality kidneys.

A2 incompatible kidney transplantation does not adversely affect graft or patient survival.

The new United Network for Organ Sharing (UNOS) kidney allocation system (KAS) incorporates A2 and A2B to B transplantation to reduce wait times for blood group B candidates. Few studies have employed multicenter data or comprehensively defined donor‐to‐recipient ABO classification systems.

Continuous versus bolus tube feeds: Does the modality affect glycemic variability, tube feeding volume, caloric intake, or insulin utilization?

Introduction: Enteral nutrition (EN) is very important to optimizing outcomes in critical illness. Debate exists regarding the best strategy for enteral tube feeding (TF), with concerns that bolus TF (BTF) may increase glycemic variability (GV) but result in fewer nutritional interruptions than continuous TF (CTF). This study examines if there is a difference in GV, insulin usage, TF volume, and caloric delivery among intensive care patients receiving BTF versus CTF. We hypothesize that there are no significant differences between CTF and BTF when comparing the above parameters. Materials and Methods: Prospective, randomized pilot study of critically ill adult patients undergoing percutaneous endoscopic gastrostomy (PEG) placement for EN was performed between March 1, 2012 and May 15, 2014. Patients were randomized to BTF or CTF. Glucose values, insulin use, TF volume, and calories administered were recorded. Data were organized into 12-h epochs for statistical analyses and GV determination. In addition, time to ≥80% nutritional delivery goal, demographics, Acute Physiology and Chronic Health Evaluation II scores, and TF interruptions were examined. When performing BTF versus CTF assessments, continuous parameters were compared using Mann–Whitney U-test or repeated measures t-test, as appropriate. Categorical data were analyzed using Fishers exact test. Results: No significant demographic or physiologic differences between the CTF (n = 24) and BTF (n = 26) groups were seen. The immediate post-PEG 12-h epoch showed significantly lower GV and median TF volume for patients in the CTF group. All subsequent epochs (up to 18 days post-PEG) showed no differences in GV, insulin use, TF volume, or caloric intake. Insulin use for both groups increased when comparing the first 24 h post-PEG values to measurements from day 8. There were no differences in TF interruptions, time to ≥80% nutritional delivery goal, or hypoglycemic episodes. Conclusions: This study demonstrated no clinically relevant differences in GV, insulin use, TF volume or caloric intake between BTF and CTF groups. Despite some shortcomings, our data suggest that providers should not feel limited to BTF or CTF because of concerns for GV, time to goal nutrition, insulin use, or caloric intake, and should consider other factors such as resource utilization, ease of administration, and/or institutional/patient characteristics.

Proceedings of the American Society for Enhanced Recovery/Evidence Based Peri-Operative Medicine 2016 Annual Congress of Enhanced Recovery and Perioperative Medicine

Table of contentsA1 Effects of enhanced recovery pathways on renal functionCharles R. Horres, Mohamed A. Adam, Zhifei Sun, Julie K. Thacker, Timothy J. Miller, Stuart A. GrantA2 Economic outcomes of enhanced recovery after surgery (ERAS)Jeffrey HuangA3 What does eating, drinking and mobilizing after enhanced recovery surgery really mean?Kirstie McPherson, Sanjiv Patel, Su Cheen Ng, Denise Veelo, Bart Geerts, Monty MythenA4 Intra-operative fluid monitoring practicesSu Cheen Ng, Mark Foulger, Tim Collins, Kirstie McPherson, Michael MythenA5 Development of an integrated perioperative medicine care pathwayMark Edwards, Denny Levett, Tristan Chapman, Imogen Fecher – Jones, Julian Smith, John Knight, Michael GrocottA6 Cardiopulmonary exercise testing for collaborative decision making prior to major hepatobiliary surgeryMark Edwards, Thomas Sharp, Sandy Jack, Tom Armstrong, John Primrose, Michael Grocott, Denny LevettA7 Effect of an enhanced recovery program on length of stay for microvascular breast reconstruction patientsAdam B. King, Kye Higdon, Melissa Bellomy, Sandy An, Paul St. Jacques, Jon Wanderer, Matthew McEvoyA8 Addressing readmissions associated with an enhanced recovery pathway for colorectal surgeryAnne C. Fabrizio, Michael C. Grant, Deborah Hobson, Jonathan Efron, Susan Gearhart, Bashar Safar, Sandy Fang, Christopher Wu, Elizabeth WickA9 The Manchester surgical outcomes project: prevalence of pre operative anaemia and peri operative red cell transfusion ratesLeanne Darwin, John MooreA10 Preliminary results from a pilot study utilizing ears protocol in living donor nephrectomyAparna Rege, Jayanth Reddy, William Irish, Ahmad Zaaroura, Elizabeth Flores Vera, Deepak Vikraman, Todd Brennan, Debra Sudan, Kadiyala RavindraA11 Enhanced recovery after surgery: the role of the pathway coordinatorDeborah WatsonA12 Hospitalization costs for patients undergoing orthopedic surgery treated with intravenous acetaminophen (IV-APAP) + IV opioids or IV opioids alone for postoperative painManasee V. Shah, Brett A. Maiese, Michael T. Eaddy, Orsolya Lunacsek, An Pham, George J. WanA13 Development of an app for quality improvement in enhanced recoveryKirstie McPherson, Thomas Keen, Monty MythenA14 A clinical rotation in enhanced recovery pathways and evidence based perioperative medicine for medical studentsAlexander B Stone, Christopher L. Wu, Elizabeth C. WickA15 Enhanced recovery after surgery (ERAS) implementation in abdominal based free flap breast reconstructionRachel A. Anolik, Adam Glener, Thomas J. Hopkins, Scott T. Hollenbeck, Julie K. Marosky ThackerA16 How the implementation of an enhanced recovery after surgery (ERAS) protocol can improve outcomes for patients undergoing cystectomyTracey Hong, Andrea Bisaillon, Peter Black, Alan So, Associate Professor, Kelly MaysonA17 Use of an app to improve patient engagement with enhanced recovery pathwaysKirstie McPherson, Thomas Keen, Monty MythenA18 Effect of an enhanced recovery after surgery pathway for living donor nephrectomy patientsAdam B. King, Rachel Forbes, Brad Koss, Tracy McGrane, Warren S. Sandberg, Jonathan Wanderer, Matthew McEvoyA19 Introduction and implementation of an enhanced recovery program to a general surgery practice in a community hospitalPatrick Shanahan, John Rohan, Desirée Chappell, Carrie ChesherA20 “Get fit” for surgery: benefits of a prehabilitation clinic for an enhanced recovery program for colorectal surgical patientsSusan VanderBeek, Rebekah KellyA21 Evaluation of gastrointestinal complications following radical cystectomy using enhanced recovery protocolSiamak Daneshmand, Soroush T. Bazargani, Hamed Ahmadi, Gus Miranda, Jie Cai, Anne K. Schuckman, Hooman DjaladatA22 Impact of a novel diabetic management protocol for carbohydrate loaded patients within an orthopedic ERAS protocolVolz L, Milby JA23 Institution of a patient blood management program to decrease blood transfusions in elective knee and hip arthroplastyOpeyemi Popoola, Tanisha Reid, Luciana Mullan, Mehrdad Rafizadeh, Richard Pitera

Impact of chlorhexidine mouthwash prophylaxis on probable ventilator-associated pneumonia in a surgical intensive care unit.

Background: Prevention of ventilator-associated pneumonia is a healthcare goal. Although data is inconsistent, some studies suggest that oral chlorhexidine may decrease rates of pneumonia in mechanically-ventilated patients. We sought to assess the rate of pneumonia in the Surgical Intensive Care Unit (SICU) pre and post implementation of routine chlorhexidine mouthwash prophylaxis. Materials and Methods: A retrospective cohort study was conducted, including patients between 1/1/2009 and 12/31/2009 who did not receive chlorhexidine mouthwash compared to patients that received prophylactic chlorhexidine mouthwash between 3/1/2010 and 2/28/2011. The primary outcome of the study was rate of probable ventilator-associated pneumonia (VAP) for the pre-chlorhexidine implementation cohort compared to post-implementation, using the 2013 Center for Disease Control definitions. Mechanically ventilated patients with respiratory cultures were screened for inclusion in the study. Secondary endpoints included duration of mechanical ventilation, in-hospital mortality, ICU and hospital length of stay. Statistical analysis was conducted by Fishers exact test for nominal data and Mann-Whitney U test for continuous data. Results: A total of 1780 mechanically ventilated patients in the pre-chlorhexidine group and 1854 in the post-chlorhexidine group were screened for inclusion. Of the 601 mechanically ventilated patients that were further evaluated for inclusion; 158 patients (26.3%) had positive cultures and were included in the study (94 pre-group and 64 post-group). The rate of probable VAP was significantly decreased in the post-group compared to the pre-group (1.85% pre vs 0.81% post, P = 0.0082). Conclusion: Use of chlorhexidine mouthwash prophylaxis may reduce rates of probable VAP. Further study is warranted.

Increasing kidney donor profile index sequence does not adversely affect medium-term health-related quality of life after kidney transplantation

The United Network for Organ Sharing system allocates deceased donor kidneys based on the kidney donor profile index (KDPI), stratified as sequences (A ≤ 20%, B > 20‐<35%, C ≥ 35‐≤85%, and D > 85%), with increasing KDPI associated with decreased graft survival. While health‐related quality of life (HRQOL) may improve after transplantation, the effect of donor kidney quality, reflected by KDPI sequence, on post‐transplant HRQOL has not been reported.

A2 to B Blood Type Incompatible Deceased Donor Kidney Transplantation in a Recipient Infected with the Human Immunodeficiency Virus: A Case Report.

BACKGROUND With the introduction of the Kidney Allocation System in the United States in December 2014, transplant centers can list eligible B blood type recipients for A2 organ offers. There have been no prior reports of ABO incompatible A2 to B deceased donor kidney transplantation in human immunodeficiency virus-positive (HIV+) recipients to guide clinicians on enrolling or performing A2 to B transplantations in HIV+ candidates. We are the first to report a case of A2 to B deceased donor kidney transplantation in an HIV+ recipient with good intermediate-term results. METHODS AND RESULTS We describe an HIV+ 39-year-old African American man with end-stage renal disease who underwent A2 to B blood type incompatible deceased donor kidney transplantation. Prior to transplantation, he had an undetectable HIV viral load. The patient was unsensitized, with his most recent anti-A titer data being 1:2 IgG and 1:32 IgG/IgM. Induction therapy of basiliximab and methylprednisolone was followed by a postoperative regimen of plasma exchange, intravenous immunoglobulin, and rituximab with maintenance on tacrolimus, mycophenolate mofetil, and prednisone. He had delayed graft function without rejection on allograft biopsy. Nadir serum creatinine was 2.0 mg/dL. He continued to have an undetectable viral load on the same antiretroviral therapy adjusted for renal function. CONCLUSIONS To our knowledge, this is the first report of A2 to B deceased donor kidney transplantation in an HIV+ recipient with good intermediate-term results, suggesting that A2 donor kidneys may be considered for transplantation into HIV+ B-blood type wait list candidates.

Intraoperative Management of the Kidney Transplant Recipient

Purpose of ReviewThe purpose of this study was to review current literature on the intraoperative management of the kidney transplant recipient in terms of preoperative evaluation, anesthetic agents of choice, monitoring needs, intraoperative fluid and hemodynamic management, and perioperative pain control options.Recent FindingsMore recent literature regarding intraoperative kidney management suggests less aggressive volume loading with a balanced crystalloid solution, particularly in regard to albumin and blood products, with increased consideration for multimodal therapies for nausea and pain control.SummaryPerioperative kidney management is crucial to immediate- and long-term outcomes for graft and patient survival. Surgical and anesthetic techniques should continue to be honed to allow for ideal renal perfusion intraoperatively. Considerations for intraoperative optimization for renal transplantation include the appropriate types and volume of fluid based on cardiac risk factors with the increasing number of elderly recipients, the avoidance of vasoconstrictive agents, and a reduction in perioperative cardiac-depressing agents for pain that may be managed by multimodal therapies.

The Kidney Transplant Evaluation Process in the Elderly: Reasons for Being Turned down and Opportunities to Improve Cost-Effectiveness in a Single Center

Background. The kidney transplant evaluation process for older candidates is complex due to the presence of multiple comorbid conditions. Methods. We retrospectively reviewed patients ≥60 years referred to our center for kidney transplantation over a 3-year period. Variables were collected to identify reasons for patients being turned down and to determine the number of unnecessary tests performed. Statistical analysis was performed to estimate the association between clinical predictors and listing status. Results. 345 patients were included in the statistical analysis. 31.6% of patients were turned down: 44% due to coronary artery disease (CAD), peripheral vascular disease (PVD), or both. After adjustment for patient demographics and comorbid conditions, history of CAD, PVD, or both (OR = 1.75, 95% CI (1.20, 2.56), p = 0.004), chronic obstructive pulmonary disease (OR = 8.75, 95% CI (2.81, 27.20), p = 0.0002), and cancer (OR 2.59, 95% CI (1.18, 5.67), p = 0.02) were associated with a higher risk of being turned down. 14.8% of patients underwent unnecessary basic testing and 9.6% underwent unnecessary supplementary testing with the charges over a 3-year period estimated at

Can enteral antibiotics be used to treat pneumonia in the surgical intensive care unit? A clinical outcomes and cost comparison.

304,337. Conclusion. A significant number of older candidates are deemed unacceptable for kidney transplantation with primary reasons cited as CAD and PVD. The overall burden of unnecessary testing is substantial and potentially avoidable.