Progress in Transplantation

To describe the pharmacology and safety of oral over-the-counter cough suppressants and expectorants and to present recommendations for the use of these agents in solid-organ transplant recipients based on the potential for adverse drug reactions or drug-disease interactions.

Data from journal articles and other sources describing the pharmacology and safety of over-the-counter cough suppressants and expectorants, drug-drug interactions with immunosuppressive agents, and drug-disease state interactions are reviewed.

Potential and documented drug-drug interactions between immunosuppressive agents and over-the-counter cough medications guaifenesin, dextromethorphan, diphenhydramine, and codeine were evaluated on the basis of pharmacokinetic and pharmacodynamic principles. Interactions between these cough medications and the physiological changes in the body following transplantation also were examined.

Diphenhydramine requires additional monitoring when used to treat cough in transplant recipients owing to its anticholinergic properties and the potential for interactions with cyclosporine. Dextromethorphan can be used in most transplant recipients, although greater caution should be exercised if the patient has undergone liver transplant or has liver impairment. Guaifenesin can be used in transplant recipients but should be used with caution in patients receiving kidney or lung transplants and in patients with renal impairment. Codeine combined with guaifenesin is another option for cough and can be used in most transplant patients although those with reduced renal function should be monitored carefully for adverse events.

To identify the current clinical practices of Medicare-certified facilities offering ventricular assist devices as destination therapy and to attain a consensus of recommended clinical practices across the United States for the management of adults with ventricular assist devices as destination therapy.

Sixty ventricular assist device coordinators from Medicare-certified centers were invited to participate in an online, 2-round Delphi survey. The surveys asked whether recommended practices are current practices and whether respondents always/agreed or never/disagreed with performing the recommended practice guidelines. Consensus was defined as 75% agreement. The clinical areas of focus were patient selection, preoperative preparation, postoperative care, infection control, nutrition, and patient discharge preparation. Practices were extracted from the advanced practice guidelines for HeartMate destination therapy and the International Society for Heart and Lung Transplantation's 2006 guidelines for the care of heart transplant candidates.

Representing 21 states across the country, the first-round survey had a response rate of 57% (n = 34). The second-round survey had a response rate of 74% (n= 17), representing 28% of the 60 centers. Consensus was obtained for 122 practices. The dimension of patient selection—diagnostic tests and screening had the highest level of consensus (16%, n = 20), and the dimension of postoperative care—intermediate/intensive care unit dimension had the lowest level of consensus (3.3%, n = 4).

Survey results identify a consensus of practices for the specific group of ventricular assist device coordinators who responded, but that consensus cannot be generalized to all ventricular assist device facilities. These results can, however, provide a foundation for further research leading to the development of standard-of-care practices for patients with ventricular assist devices as destination therapy.

Poor sleep quality and poor daytime functioning affect many kidney transplant patients.

To evaluate the validity of 2 items assessing sleep quality and daytime functioning using the Pittsburgh Sleep Quality Index as reference standard before use in a large cohort study, following the American Psychological Association's guidelines.

A cross-sectional study using a psychosocial questionnaire developed for a large cohort study and the Pittsburgh Sleep Quality Index.

One hundred thirty-five home-dwelling kidney transplant patients aged 21 to 76 years (mean, 51.6 years; SD, 11.9 years).

Evidence on content, internal structure, and relation to other variables.

The Pittsburgh Sleep Quality Index indicated a 47.4% prevalence of poor sleep quality; the sleep quality item in the psychosocial questionnaire showed a 30.7% prevalence of poor sleep quality and a 34.1% prevalence of poor daytime functioning. Content validity was good for the psychosocial questionnaire's sleep quality item but poor for its daytime functioning item. As hypothesized, the psychosocial questionnaire's sleep quality item was moderately correlated with its daytime functioning item (Spearman rho, ρ_s = 0.520, P< .001), indicating related but distinct concepts. When combined, the 2 items from the psychosocial questionnaire showed significant correlations with the total score on the Pittsburgh Sleep Quality Index (ρ_s = −0.784, P< .001), depressive symptoms (ρ_s = −0.680, P< .001), perceived health status (ρ_s = 0.619, P< .001), and subjective health status (ρ_s = 0.671, P< .001) in the expected directions.

For kidney transplant patients, validity is strong for the psychosocial questionnaire's sleep quality item, but the mixed findings regarding the validity of the daytime functioning item suggest that additional items are needed to measure daytime functioning.

Many transplant candidates have concerns about living donation.

To determine whether a structured educational session increased eligible kidney transplant candidates' pursuit of living donation.

Eligible transplant candidates were randomized to standard of care (n = 50) or to the educational intervention (n = 50), which included both written materials and a 2-hour education session. The primary outcome was having a living donor contact the transplant program to express interest in donation for a patient, and a secondary outcome was the candidates' preference for treatment of end-stage renal disease; both outcomes were determined at 3 months after enrollment.

Of the 100 patients randomized, 4 in the intervention group and 2 in the standard of care group had a living donor contact the program (P = .45). Within-group changes in treatment preference from baseline were seen in the education intervention group (P = .02), but not in the standard of care group (P = .37).

This educational intervention did not increase the likelihood of a potential donor contacting the transplant program, compared with standard care. However, patients who received the educational intervention were more likely to change their treatment preference to living donation at study completion. Research investigating other methods of increasing living transplant rates is urgently required.

Clinical pathways have been used in many acute hospital settings.

To develop a systematic approach to postoperative care of adult recipients of deceased donor kidney transplants at the University of Mississippi Medical Center.

A pilot quality improvement project that uses implementation of a clinical pathway 24 hours after surgery for adult recipients of a deceased donor kidney transplant for 7 months. Charts from the same 7 months of the preceding year were retrospectively reviewed for comparison. The project occurred on the transplant floor in an acute care hospital and did not include any patients admitted to the intensive care unit.

To demonstrate that clinical pathways can (1) promote a method for standardizing postoperative care, (2) decrease postoperative length of stay, and (3) contain costs by minimizing hospital charges related to laboratory and room fees and promote efficient medication use in adult recipients of a deceased donor kidney transplant.

All 24 patients in the clinical pathway group met daily goals of the implemented clinical pathway. The clinical pathway group had statistically significant decreases in postoperative length of stay, use of laboratory tests, and use of intravenous medications compared with the comparison group. The 2 groups were similar in race, sex, age, and body mass index. Surgical readmissions did not differ significantly between the 2 groups.

Adolescents are at higher risk for organ loss than are all other age groups, but no studies have been conducted to examine the specific information needs of adolescents. A better understanding of adolescents' information needs is essential for developing programs tailored to their unique requirements.

To explore information needs of adolescents who have undergone kidney transplantation in order to inform development of an education program.

A qualitative descriptive design was used. Focus groups (n = 2) were conducted by using a semistructured interview guide. Transcribed data were organized into categories that reflected emerging themes by using simple content analysis.

A convenience sample of 8 adolescents (50% female) who varied in age, donor type, and time since transplantation were recruited from a large Canadian tertiary care pediatric center.

Adolescents articulated that the process of undergoing kidney transplant was very stressful and affected all aspects of their lives. In particular, adolescents identified 4 main stressors: changes in body image, wanting to be normal, pain, and breakdown in communication processes. The 2 strategies that assisted adolescents in coping with these stressors were (1) gaining knowledge about the transplantation process and (2) experiencing understanding through social support. They wanted information provided to them gradually throughout the transplant experience with choices given as to how they receive the information.

Adolescents were united in their call for information, self-management strategies, and meaningful social support to better manage their kidney transplant and prepare for transition to adult health care.

Characteristic adolescent risk-taking behavior, including nonadherence with prescribed medications, can be life-threatening for transplant recipients. Suggestions for managing nonadherence in teen recipients include providing them and their parents with adequate information about medications, talking with and listening to pediatric recipients about problems with the comprehensive regimen, and encouraging age-appropriate responsibility for maintaining health.

The clinical goal of this project was to develop a structured age-appropriate educational program to prepare pediatric transplant recipients and their families for the patient's life as a responsible, independent individual. Our primary research goal was to assess patients' and parents' knowledge about critical aspects of heart transplantation and the treatment regimen with brief questionnaires before and after they received the educational materials from their primary nurse coordinator.

This descriptive pre-post test study was done to assess the effectiveness of an innovative family-centered educational program among 20 pediatric heart transplant recipients and their parents at Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center.

Percentage change in children's scores on questionnaires given before and after the educational intervention ranged from $8% to 300% (mean, 64.1%). Percentage change in scores from before to after for parents ranged from $19% to 53.8% (mean, 7.2%).