Holistic Long-Term Care Over Elderly Kidney Transplant Recipients

Accepted Manuscript Holistic long-term care over elderly kidney transplant recipients Elzbieta Wlodarczyk, Zbigniew Wlodarczyk, Leszek Paczek, Agnieszka Szymanska, Maciej Glyda, Andrzej Adamowicz, Grazyna Baczyk, Agnieszka Ulatowska PII:

S0041-1345(18)30648-1

DOI:

10.1016/j.transproceed.2018.04.051

Reference:

TPS 28532

To appear in:

Transplantation Proceedings

Received Date: 30 December 2017 Revised Date:

10 April 2018

Accepted Date: 24 April 2018

Please cite this article as: Wlodarczyk E, Wlodarczyk Z, Paczek L, Szymanska A, Glyda M, Adamowicz A, Baczyk G, Ulatowska A, Holistic long-term care over elderly kidney transplant recipients, Transplantation Proceedings (2018), doi: 10.1016/j.transproceed.2018.04.051. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT Title: Holistic long-term care over elderly kidney transplant recipients

Authors: 1

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Glyda , Andrzej Adamowicz , Grazyna Baczyk Agnieszka Ulatowska

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Department of Geriatrics, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University Department of Transplantology and General Surgery, Collegium Medicum in Bydgoszcz, Nicolaus

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Affiliations:

Copernicus University

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Department of Immunology, Transplantology and Internal Medicine, Warsaw Medical University Department of Transplantology and General Surgery, Poznan District Hospital Faculty of Nursing, Poznan Medical University

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Elzbieta Wlodarczyk , Zbigniew Wlodarczyk , Leszek Paczek , Agnieszka Szymanska , Maciej

Email addresses of authors:

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:

Elzbieta Wlodarczyk [email protected]

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Zbigniew Wlodarczyk: [email protected] Leszek Paczek: [email protected] Agnieszka Szymanska: [email protected] Maciej Glyda: [email protected] Andrzej Adamowicz: [email protected] Grazyna Baczyk: [email protected] Agnieszka Ulatowska: [email protected]

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Corresponding author Zbigniew Wlodarczyk Department of Transplantology and General Surgery

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M. Sklodowskiej-Curie 9 85-094 Bydgoszcz e-mail: [email protected]

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Telephone: +48 52 585 4380

Grant information:

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No grant

Tables: 2

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Figures: 0

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Key words: kidney transplantation, outpatient care, elderly recipient

ACCEPTED MANUSCRIPT Abstract Kidney transplantation is an optimal method of renal replacement therapy in patients with phase V chronic kidney disease. Elderly patients (>60 years of age) with a kidney transplant create a significant and constantly growing pool of patients with this type of organ transplantation.

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In this group of patients, long-term care should be particularly stringent and vigilant. Apart from typical conditions associated with chronic kidney disease and possible post-transplant complications as well as side effects of immunosuppressive treatment, the patient also experiences changes and limitations associated with the progress of age and diseases typical for old age, characterized by a

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higher risk of infection, and changed pharmacokinetics /pharmacodynamics. Undoubtedly, patients should remain under medical care of qualified transplantologist, but constant cooperation with a

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general practitioner and geriatrician would be of added value. Study results show that although most of the elderly kidney recipients have constant contact with their general practitioner, and almost half of them use private care, contribution of the geriatrician to the transplant care system is unsatisfactory,

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and elderly kidney recipients would expect more extensive outpatient care.

ACCEPTED MANUSCRIPT Introduction Over the last decade, the percentage of kidney recipients older than 60 years significantly increased and currently exceeds 30%. This is a contemporary demographic process resulting in the increasing proportion of older age-groups in the pool of kidney transplant recipients.

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Therefore, this procedure is becoming a standard in treating end-stage renal failure among these patients [1].

This extremely sensitive group of recipients, due to the multitude of hazards and

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complications associated with the ageing process, require a holistic approach and long-term care. They are exposed to a higher risk of a kidney loss, including the death of the recipient, in

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comparison to younger recipients [2]. Long-term medical care concerning these patients should be defined with relevant standards and involve transplantologists, geriatricians and primary health care specialists [3].

Multiple morbidities, such as arterial hypertension, hyperlipidaemia, post-transplant diabetes,

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age-related diseases and limitations as well as polypharmacy together with its implications, such as post-immunosuppression complications, drug interactions, side effects and changed

recipients [4].

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pharmacokinetics/pharmacodynamics, determine the distinctness of a geriatric renal transplant

Following successful kidney transplantation and postoperative treatment, the patient returns to

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his/hers environment, where he/she should be immediately subjected to the care of a general practitioner and community nurse [5]. Long-term care under the supervision of transplantologists ensures regular visits. It includes examinations and monitoring of the graft function, immunosuppressive treatment and its possible complications, as well as the education of the patients and support from professionals in the clinic. However, this care does not cover typical geriatric conditions, especially in terms of holistic care, which each elderly kidney recipient should be subject to. This aspect of

ACCEPTED MANUSCRIPT medical care should be secured by the primary health care doctor – general practitioner (GP) and a geriatrics specialist. Therefore, in theory, GP has all the responsibilities, rights and measures in order to take supplementary care of an elderly patient after a kidney transplantation [6].

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Unfortunately, it seems that general practitioners do not attempt complex management of post-transplant patients, and the patients seem to identify themselves more strongly with the Outpatient Transplant Clinic (OTC), neglecting regular visits to their GP. Most probably, they

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are not referred to the geriatrician at all.

Without a doubt, post-transplant patients require special medical care and specialist

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examinations, which - out of necessity - are performed by extensively burdened Transplantation Clinics. However, due to the need for holistic care over these patients, continuous surveillance, faster and more frequent contact with the patient in his/hers environment, primary health care facilities, together with geriatric clinics should take over a

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significant part of these services

Aim of the study

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The aim of the study was to asses, whether elderly kidney transplant recipients, apart from long-term follow-up at the transplant outpatient clinic, are supported by primary health care

care.

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specialists (GP, community nurse) and geriatricians, and to evaluate the efficiency of such

Material and methods 300 consecutive kidney transplant recipients were invited to the study during scheduled visit at the Outpatient Transplant Clinic. The only inclusion criteria were: age over 60, functioning graft (regardless its function, but no need for dialysis) and willingness to complete the

ACCEPTED MANUSCRIPT questionnaire. Patients were handed over the authorial questionnaire, containing questions regarding the number and frequency of the visits at the transplant clinic, primary health care specialist, geriatrician and district nurse. Patients were also inquired about possible and additional use of private (paid) health service, as well as possible expectation for additional

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care. Questionnaires were completed and collected at the same visit. No personal data were noted.

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Statistical evaluation

Demographic data were presented as a percentage of the total number of patients.

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Results were presented as a percentage of the total number and evaluated with one-sample ztest for proportions for large pool. P-value was is calculated using chi

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and general z-test, and

considered significant when less than 0,05 [7].

In order to evaluate the statistical significance, we assumed zero hypothesis (assumed

Results

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percentage) for each statistical calculation.

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The average age was 65,9 years (60-82). The time from onset of kidney disease varied from 4 to 40 years, and the average time from transplantation was 97 months (5 to 323) . Only 2 recipient had

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kidneys from living donors, all remaining grafts were cadaveric. Most of the patients visited Transplant Outpatient Clinic 3-4 times per year (83,9%n=225). Only small fraction (1,9%, n=5) were seen less often, but 37 out of 267 (13,8%n=37) of recipients required or demanded more frequent visits (more than 12 per year). Surprisingly, vast majority of patients (significantly more than assumed) were parallel seeing primary health care specialists/general practitioners (95% vs 5%). Such visits were less frequent, but exactly half of the patients were visiting GPs at least 4 times per year – as often as the Transplant Clinic.

ACCEPTED MANUSCRIPT Neither the age, nor the gender correlated with frequency or type of outpatient care. The only significant correlation found was that with post-transplant diabetes as a primary disease and type of outpatient care (visiting GP or community nurse). Despite that, only 1/3 applied for or were referred to the community nurse care (smaller

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proportion, than assumed). Almost none (only 1,1%, n=3) of the recipients were referred to the geriatrician. Less than assumed (68,2%) were satisfied with the extent of the medical care

the recipients) were seeking additional, paid medical care.

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Results are presented in Table 1 and Table 2

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provided, and remaining expressed the need for additional medical care. More than expected (53% of

Discussion

Although multicentre, our study is based on single-country data and therefore reflects the Polish healthcare system, especially in the aspects of long-term post-transplant care.

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However, it can be assumed that, in general, it is similar to the post-transplant care systems across the Europe, and – therefore – conclusions drawn from this study may be to some

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extend - universal.

The subgroup of kidney recipients – aged 60 and over - is constantly increasing, and their

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post-transplant long term care should be holistic and specific in relation to the complexity of the health-related problems, arising not only from the kidney disease and immunosuppression, but also from the advanced age. Although the average age in our study group was 65,7 years, the oldest recipient was 82 years old. Such age structure is now common, as shown by the international data [2, 8, 9]. Preferably, the long-term post-transplant care should be conducted by Outpatient Transplant Clinics (OTC) [10]. Results of our study revealed that most of our patients are seen at the TOC at least four times a year, or even more frequently. Surprisingly enough, they

ACCEPTED MANUSCRIPT concurrently use the service provided by their GPs, although less frequently. This is in part convergent with data from other countries with established cooperation between transplant specialists and general practitioners [11]. Diabetes, as the primary diagnosis or co-morbidity

the intensity of the transplant outpatient care.

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seemed to increase the demand for both GP and community nurse care, but did not influenced

On the other hand, it may reflect the situation where transplant specialist in OTC deals only with specific post-transplant health problems, minimising or neglecting age-related

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complains.

One would expect that post-transplant primary health care would be reinforced by support of

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the community nurse. This was the fact only in 1/3 of our patients, and even then, they were seen by community nurse on rather rare occasions (1-4 per year). This is on the contrary to the published data from UK, where community nurses take over several responsibilities within primary health care system [11].

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Geriatric consultations seem to be neglected – only 1% of patients were ever referred to the geriatrician. It needs to be stressed that elderly kidney transplant recipient require holistic care, and health problems related to the advanced age should be consulted and managed by

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geriatrician. On the other hand, only 1/3 of our recipients expressed need for additional health care, remaining being satisfied. One would prefer this to be the proof of sufficient post-

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transplant care, but it rather reveals the deficiency of knowledge – patients may not be aware that geriatric care should accompany the post – transplant long-term follow-up.

Conclusions 1. Elderly kidney recipients require holistic and coordinated long-term care 2. Transplant Outpatient Clinics provide regular follow-up for elderly kidney recipients

ACCEPTED MANUSCRIPT 3. Service provided by general practitioners may overlap, but should not supersede the transplant specialists care 4. There is need for more intense involvement of community nurse and geriatricians in

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the long-term post-transplant care.

References

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1. Sutherland AI, Izermans JN, Forsythe JL, Dor FJ. Kidney and liver transplantation in the elderly. Br J Surg. 2016 Jan;103(2): 62-72.

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2. Rao PS, Merion RM, Ashby VB, Port FK, Wolfe RA, Kayler LK. Renal transplantation in elderly patients older than 70 years of age: results from the Scientific Registry of Transplant Recipients. Transplantation 2007; 83: 1069–1074

3. Dempster NJ, Ceresa CD, Aitken E, Kingsmore D. Outcomes following renal transplantation in older people: a retrospective cohort study. BMC Geriatr 2013; 13: 79.

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4. Knoll I, Greg A. Kidney Transplantation in the Older Adult. American Journal of Kidney Diseases, Volume 61, Issue 5 , 790 - 797

5. Wong CJ, Pagalilauan G. Primary Care of the Solid Organ Transplant Recipient. Med Clin North

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Am. 2015 Sep;99(5):1075-103

6. Cimino FM, Snyder KA. Primary Care of the Solid Organ Transplant Recipient. Am Fam

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Physician. 2016 Feb 1;93(3):203-10. 7. Altman DG. Practical statistics for medical research. London 1991: Chapman and Hall. 8. Curtis JJ: Ageism and kidney transplantation. Am J Transplant. 2006, 6 (6): 1264-1266 9. Marconi L, Figueiredo A, Campos L, Nunes P, Roseiro A, Parada B, Mota A. Renal transplantation with donors older than 70 years: does age matter? Transplant Proc. 2013 Apr;45(3):1251-4. 10. Khwaja A. KDIGO guidelines for care of the kidney transplant recipient. Nephron Clin Pract. 2010;116(1)

ACCEPTED MANUSCRIPT 11. Whittaker C, Dunsmore V, Murphy F, Rolfe C, Trevitt R. Long-term care and nursing management of a patient who is the recipient of a renal transplant. J Ren Care. 2012 Dec;38(4):233-

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40.

ACCEPTED MANUSCRIPT Frequent (>12 per year) visits at Transplant Outpatient Clinic n=37

Visiting GP n=253

Referral to the community nurse n=80

Age (60-82, mean 65,9) Age distribution below 60-64, n=119 65-70, n=105 71-75, n=33 >75, n=10

p=ns

p=ns

p=ns

n=11 n=9 n=6 n=8

n=115 n=99 n=30 n=9

n=27 n=35 n=12 n=6

Gender Gender F, n=113 Gender M, n=154

p=ns n=16 n=21

p=ns n=107 n=146

Time post transplant (months, 5-323, mean 97) Time post transplant distribution below <50 51-100 >100

p=ns

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Matrix of correlations

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p=ns

Diabetes mellitus n=64

p=ns n=37 n=43 p=ns

n=21 n=9 n=7

n=108 n=115 n=30

n=17 n=34 n=29

n=38

n=62 p<0,05

n=57 p<0,05

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Table 1. Correlations between demographic factors and modes of post-transplant outpatient care.

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Referred to geriatric specialist

75%

Need for additional medical care

25%

Use of additional, paid healthcare

25%

Z value

P value

N=253 94,76 N=80 29,96% N=3 1,12% N=85 31,83% N=142 53,18

N=14 5,24% N=187 70,04% N=264 98,88% N=182 68,16% N=125 46,82

7,457

<0,001

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75%

no

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Table 2. Percentage of recipients under supplementary medical care

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16,996

<0,001

27,879

<0,001

2,577

=0,01

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Referred to community nurse

yes

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Under parallel care of GP

Assumed (H0 hypothesis) 75%

10,624

<0,001

ACCEPTED MANUSCRIPT Research highlights

1. Elderly kidney recipients require holistic and coordinated long-term care 2. Transplant Outpatient Clinics provide regular follow-up for elderly kidney recipients 3. Service provided by general practitioners may overlap, but not comply with transplant

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specialists 4. There is need for more intense involvement of community nurse and geriatricians in

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the long-term post-transplant care.