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Kidney transplant recipients (KTR) have impaired health-related quality of life (HRQoL) and suffer from intestinal dysbiosis. Increasing evidence shows that gut health and HRQoL are tightly related in the general population. Here, we investigate the association between the gut microbiome and HRQoL in KTR, using metagenomic sequencing data from fecal samples collected from 507 KTR. Multiple bacterial species are associated with lower HRQoL, many of which have previously been associated with adverse health conditions. Gut microbiome distance to the general population is highest among KTR with an impaired physical HRQoL (R = −0.20, P = 2.3 × 10−65) and mental HRQoL (R = −0.14, P = 1.3 × 10−3). Physical and mental HRQoL explain a significant part of variance in the gut microbiome (R2 = 0.58%, FDR = 5.43 × 10−4 and R2 = 0.37%, FDR = 1.38 × 10−3, respectively). Additionally, multiple metabolic and neuroactive pathways (gut brain modules) are associated with lower HRQoL. While the observational design of our study does not allow us to analyze causality, we provide a comprehensive overview of the associations between the gut microbiome and HRQoL while controlling for confounders.Here, Swarte et al. use metagenomics to investigate the association between the gut microbiome and Health-Related Quality of Life (HRQoL) in kidney transplant recipients, showing evidence for the association of multiple taxonomic, metabolic and neuroactive pathways (gut brain modules) with lower HRQoL, together suggesting potential modifiable gut microbial factors to improve HRQoL. [ABSTRACT FROM AUTHOR]

Kidney transplant recipients (KTRs) experience more fatigue, anxiety, and depressive symptoms and lower concentration and health-related quality of life (HRQoL) compared with the general population. Anemia is a potential cause that is well-recognized and treated. Iron deficiency, however, is often unrecognized, despite its potential detrimental effects related to and unrelated to anemia. We investigated the interplay of anemia, iron deficiency, and patient-reported outcomes in 814 outpatient KTRs (62% male, age 56 ± 13 years) enrolled in the TransplantLines Biobank and Cohort Study (Groningen, The Netherlands). In total, 28% had iron deficiency (ie, transferrin saturation < 20% and ferritin < 100 μg/L), and 29% had anemia (World Health Organization criteria). In linear regression analyses, iron deficiency, but not anemia, was associated with more fatigue, worse concentration, lower wellbeing, more anxiety, more depressive symptoms, and lower HRQoL, independent of age, sex, estimated glomerular filtration rate, anemia, and other potential confounders. In the fully adjusted logistic regression models, iron deficiency was associated with an estimated 53% higher risk of severe fatigue, a 100% higher risk of major depressive symptoms, and a 51% higher chance of being at risk for sick leave/work disability. Clinical trials are needed to investigate the effect of iron deficiency correction on patient-reported outcomes and HRQoL in KTRs., Competing Interests: Declaration of competing interest The authors of this manuscript have conflicts of interest to disclose as described by the American Journal of Transplantation. M.F. Eisenga has declared receiving consultant fees from Vifor Pharma and Cablon Medical; serving on the Advisory Board for Cablon Medical and GlaxoSmithKline; and receiving speaker fees from Vifor Pharma, Pharmacosmos, and Astellas. All other authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Introduction: Patients with end-stage liver disease awaiting orthotopic liver transplantation (OLT) are generally classified as frail due to disease-related malnutrition and a progressive decline in musculoskeletal and aerobic fitness, which is associated with poor pre-OLT, peri-OLT and post-OLT outcomes. However, frailty in these patients may be reversable with adequate exercise and nutritional interventions., Methods and Analysis: Non-randomised clinical trial evaluating the effect of a home-based bimodal lifestyle programme in unfit patients with a preoperative oxygen uptake (VO 2 ) at the ventilatory anaerobic threshold ≤13 mL/kg/min and/or VO 2 at peak exercise ≤18 mL/kg/min listed for OLT at the University Medical Center Groningen (UMCG). The programme is patient tailored and comprises high-intensity interval and endurance training, and functional exercises three times per week, combined with nutritional support. Patients will go through two training periods, each lasting 6 weeks.The primary outcome of this study is the impact of the programme on patients' aerobic fitness after the first study period. Secondary outcomes include aerobic capacity after the second study period, changes in sarcopenia, anthropometry, functional mobility, perceived quality of life and fatigue, incidence of hepatic encephalopathy and microbiome composition. Moreover, number and reasons of intercurrent hospitalisations during the study and postoperative outcomes up to 12 months post OLT will be recorded. Finally, feasibility of the programme will be assessed by monitoring the participation rate and reasons for non-participation, number and severity of adverse events, and dropout rate and reasons for dropout., Ethics and Dissemination: This study was approved by the Medical Research Ethics Committee of the UMCG (registration number NL83612.042.23, August 2023) and is registered in the Clinicaltrials.gov register (NCT05853484). Good Clinical Practice guidelines and the principles of the Declaration of Helsinki will be applied. Results of this study will be submitted for presentation at (inter)national congresses and publication in peer-reviewed journals., Trial Registration Number: NCT05853484., Competing Interests: Competing interests: VEDM reports a VENI research grant by the Dutch Research Council (NWO; grant #09150161810030), a Research grant from the Dutch Ministry of Economic Affairs (Health~Holland Public Private Partnership grant #PPP-2019-024), and a Research grant from the Dutch Society for Gastroenterology (NVGE #01-2021), all outside the submitted work., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Fatigue and impaired health-related quality of life (HRQoL) are common among kidney transplant recipients (KTR). We hypothesized that both may partially be attributable to poor sleep., Methods: Cross-sectional and longitudinal data of KTR enrolled in the TransplantLines Biobank and Cohort Study were used. Sleep quality was assessed using the Pittsburgh Sleep Quality Index questionnaire. Individual strength (i.e. a composite of fatigue, concentration, motivation and physical activity), societal participation and HRQoL were assessed using validated questionnaires., Results: We included 872 KTR (39% female, age 56 ± 13 years) and 335 healthy controls. In total, 33% of male KTR and 49% of female KTR reported poor sleep quality, which was higher compared with male and female healthy controls (19% and 28%, respectively, P < .001 for both). In logistic regression analyses, female sex, anxiety, active smoking, low protein intake, physically inactive lifestyle, low plasma magnesium concentration, using calcineurin inhibitors, not using mTOR inhibitors and using benzodiazepine agonists were associated with poor sleep quality. In adjusted linear regression analyses, poor sleep was strongly and independently associated with lower individual strength [standardized β (st.β) = 0.59, 95% confidence interval (CI) 0.45 to 0.74, P < .001], poorer societal participation (frequency: st.β = -0.17, 95% CI -0.32 to -0.01, P = .04; restrictions: st.β = -0.36, 95% CI -0.51 to -0.21, P < .001; satisfaction: st.β = -0.44, 95% CI -0.59 to -0.28, P < .001) and lower HRQoL (physical: st.β = -0.53, 95% CI -0.68 to -0.38, P < .001; mental: st.β = -0.64, 95% CI -0.78 to -0.50, P < .001). The associations with poorer societal participation and lower HRQoL were strongly mediated by individual strength (P < .001 for all), yet the suggested direct effects of poor sleep quality on HRQoL remained significant (Pphysical = .03, Pmental = .002). Longitudinal data of 292 KTR showed that sleep quality improves after kidney transplantation in males (P < .001), but not in females (P = .9)., Conclusions: Poor sleep quality is common among KTR, and may be a potential target to improve fatigue, societal participation and HRQoL among KTR., (© The Author(s) 2023. Published by Oxford University Press on behalf of the ERA.)

Purpose of Review: The opportunity to review the more recent evidence for prescribing exercise-based physical rehabilitation for people living with chronic kidney disease (CKD) is timely. There has been a recent global focus evaluating how physical activity interventions might improve health-related quality of life and outcomes for people living with chronic health conditions in a post-COVID era. There is finally a long overdue commitment from the kidney research and clinical community to deliver pragmatic interventions to help people living with CKD to be able to live well with their condition., Recent Findings: This article reviews recent research, and discusses the challenges and potential solutions, for providing exercise-based therapeutic options for people living with CKD; including predialysis self-management interventions, options for both prehabilitation and posttransplant rehabilitation, pragmatic considerations for delivery of exercise therapy for people receiving haemodialysis treatment and the role of virtual kidney-specific rehabilitation., Summary: Whilst there remains a need for further research in this area of patient care, there is now a body of evidence and kidney-specific guidelines that firmly support a rollout of pragmatic and scalable exercise-based interventions for people living with CKD. We are indeed nearly there now., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: To develop a self-management instrument for organ transplant recipients that incorporates self-regulations skills and to determine its measurement properties., Methods: The instrument includes concepts from social cognitive models: problem awareness, attitude, self-efficacy, motivation, social support, goal setting, goal pursuit, skills and goal affect. The measurement properties were evaluated based on the COSMIN guidelines. Face and content validity were determined through patient assessment, Three-Step Test-Interview and expert assessment using the Content Validity Index. Structural validity and reliability were tested using exploratory factor analysis and Cronbach's alpha. Construct validity was tested by comparing subscales with the Health Education Impact Questionnaire (heiQ)., Results: After face and content validity assessment 47 items were entered into the exploratory factor analysis. The analysis showed two meaningful factors, with internal consistency of 0.90 and 0.89. Spearman correlations between the subscales and heiQ were moderate (0.55; 0.46). The final version consists of 21 items, divided into two scales: 'Setbacks' and 'Successes'., Conclusions: The Self-regulation skills instrument in transplantation (SSIt) is a valid and reliable instrument to asses necessary skills for self-management after transplantation and may be useful for other patients as well., Practice Implications: Insight into self-regulation competencies can help healthcare professionals to tailor self-management support., Competing Interests: Declaration of Competing Interest The authors declare no conflict of interest. Conflict of interest The authors declare no conflict of interest., (Copyright © 2023 The Authors. Published by Elsevier B.V. All rights reserved.)

Rationale & Objective: Prior studies report that the use of proton pump inhibitors (PPIs) can adversely affect gut microbiota and gastrointestinal uptake of micronutrients, in particular iron and magnesium, and are used frequently by kidney transplant recipients. Altered gut microbiota, iron deficiency, and magnesium deficiency have been implicated in the pathogenesis of chronic fatigue. Therefore, we hypothesized that PPI use may be an important and underappreciated cause of fatigue and reduced health-related quality of life (HRQoL) in this population., Study Design: Cross-sectional study., Setting & Participants: Kidney transplant recipients (≥1 year after transplantation) enrolled in the TransplantLines Biobank and Cohort Study., Exposure: PPI use, PPI type, PPI dosage, and duration of PPI use., Outcome: Fatigue and HRQoL, assessed using the validated Checklist Individual Strength 20 Revised questionnaire and Short Form-36 questionnaire., Analytical Approach: Logistic and linear regression., Results: We included 937 kidney transplant recipients (mean age 56±13 years, 39% female) at a median of 3 (1-10) years after transplantation. PPI use was associated with fatigue severity (regression coefficient 4.02, 95% CI, 2.18 to 5.85, P<0.001), a higher risk of severe fatigue (OR 2.05, 95% CI, 1.48 to 2.84, P<0.001), lower physical HRQoL (regression coefficient-8.54, 95% CI, -11.54 to-5.54, P<0.001), and lower mental HRQoL (regression coefficient-4.66, 95% CI, -7.15 to-2.17, P<0.001). These associations were independent of potential confounders including age, time since transplantation, history of upper gastrointestinal disease, antiplatelet therapy, and the total number of medications. They were present among all individually assessed PPI types and were dose dependent. Duration of PPI exposure was only associated with fatigue severity., Limitations: Residual confounding and inability to assess causal relationships., Conclusions: PPI use is independently associated with fatigue and lower HRQoL among kidney transplant recipients. PPI use might be an easily accessible target for alleviating fatigue and improving HRQoL among kidney transplant recipients. Further studies examining the effect of PPI exposure in this population are warranted., Plain-Language Summary: In this observational study, we investigated the association of proton pump inhibitors with fatigue and health-related quality of life among kidney transplant recipients. Our data showed that proton pump inhibitors were independently associated with fatigue severity, severe fatigue, and lower physical and mental health-related quality of life. These associations were present among all individually assessed proton pump inhibitor types and were dose dependent. While we await future studies on this topic, proton pump inhibitor use might be an easily accessible target for alleviating fatigue and improving health-related quality of life among kidney transplant recipients., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Introduction: Kidney transplant candidates (KTCs) need to be in optimal physical and psychological condition prior to surgery. However, KTCs often experience compromised functional capacity which can be characterised as frailty. Prehabilitation, the enhancement of a person's functional capacity, may be an effective intervention to improve the health status of KTCs. The PREhabilitation of CAndidates for REnal Transplantation (PreCareTx) study aims to examine the effectiveness of a multimodal prehabilitation programme on the health status of KTCs, and to explore the potential of implementation of prehabilitation in daily clinical practice., Methods and Analysis: This study uses a single centre, effectiveness-implementation hybrid type I study design, comprised of a randomised controlled trial and a mixed-methods study. Adult patients who are currently on the transplant waiting list or are waitlisted during the study period, at a university medical centre in The Netherlands, will be randomly assigned to either prehabilitation (n=64) or care as usual (n=64) groups. The prehabilitation group will undergo a 12-week home-based, tailored prehabilitation programme consisting of physical and/or nutritional and/or psychosocial interventions depending on the participant's deficits. This programme will be followed by a 12-week maintenance programme in order to enhance the incorporation of the interventions into daily life. The primary endpoint of this study is a change in frailty status as a proxy for health status. Secondary endpoints include changes in physical fitness, nutritional status, psychological well-being, quality of life and clinical outcomes. Tertiary endpoints include the safety, feasibility and acceptability of the prehabilitation programme, and the barriers and facilitators for further implementation., Ethics and Dissemination: Medical ethical approval was granted by the Medical Ethics Committee Groningen, Netherlands (M22.421). Written informed consent will be obtained from all participants. The results will be disseminated at international conferences and in peer-reviewed journals., Trial Registration Number: ClinicalTrials.gov, NCT05489432., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

There is increasingly growing evidence and awareness that prehabilitation in waitlisted solid organ transplant candidates may benefit clinical transplant outcomes and improve the patient's overall health and quality of life. Lifestyle changes, consisting of physical training, dietary management, and psychosocial interventions, aim to optimize the patient's physical and mental health before undergoing surgery, so as to enhance their ability to overcome procedure-associated stress, reduce complications, and accelerate post-operative recovery. Clinical data are promising but few, and evidence-based recommendations are scarce. To address the need for clinical guidelines, The European Society of Organ Transplantation (ESOT) convened a dedicated Working Group "Prehabilitation in Solid Organ Transplant Candidates," comprising experts in physical exercise, nutrition and psychosocial interventions, to review the literature on prehabilitation in this population, and develop recommendations. These were discussed and voted upon during the Consensus Conference in Prague, 13-15 November 2022. A high degree of consensus existed amongst all stakeholders including transplant recipients and their representatives. Ten recommendations were formulated that are a balanced representation of current published evidence and real-world practice. The findings and recommendations of the Working Group on Prehabilitation for solid organ transplant candidates are presented in this article., Competing Interests: DM is a senior researcher of The Research Foundation- Flanders. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Annema, De Smet, Castle, Overloop, Klaase, Janaudis-Ferreira, Mathur, Kouidi, Perez Saez, Matthys, Dobbels, Ferrari, Gołębiewska, Mrzljak, Girman, Perch, Lopez-Lopez, White, Koval, Greenwood and Monbaliu.)

Background: Cognitive impairment is often present shortly after transplantation in kidney transplant recipients (KTR). To date, it is unknown whether these impairments persist in thelong term, to what extent they are associated with disease-related variables and whether they affect societal participation and quality of life (QoL) of KTR., Method: This study was part of the TransplantLines Biobank & Cohort Study in the University Medical Center Groningen. A total of 131 KTR, with a mean age of 53.6 years (SD = 13.5) transplanted ≥1 year ago (M = 11.2 years, range 1-41.7 years), were included and compared with 306 healthy controls (HC). KTR and HC were well matched; there were no significant differences regarding age, sex and education. All participants were assessed with neuropsychological tests measuring memory, mental speed, attention and executive functioning, and with questionnaires examining societal participation and QoL., Results: Compared with HC, KTR performed significantly worse on memory, mental speed and measures of executive functioning (all P-values <0.05). Moreover, 16% of KTR met the criteria for mild cognitive impairment (MCI), compared with 2.6% of the HC. MCI in KTR was not significantly correlated with age- and disease-related variables. Poorer cognitive functioning was significantly related to lower levels of societal participation and to lower QoL (all P-values <0.01)., Conclusions: This study shows long-term cognitive impairments in KTR, which are not related to disease-related variables. Neuropsychological assessment is important to timely signal these impairments, given their serious negative impact on societal participation and QoL., (© The Author(s) 2022. Published by Oxford University Press on behalf of the ERA.)

Purpose of Review: To highlight the importance of biological age in the context of prehabilitation and to present relevant research regarding prehabilitation prior to solid organ transplantation., Recent Findings: Studies on the effect of prehabilitation have been performed in kidney-, lung-, liver-, and heart transplant patient populations. Prior to kidney transplantation, exercise interventions have been shown to improve cardiopulmonary- and physical fitness and result in a decreased length of hospital stay postoperatively. Among lung transplant candidates, various methods of prehabilitation have been studied including home-based, outpatient and in-patient programs, consisting of physical training, psychological support, education, and nutritional interventions. Overall, prehabilitation seems to improve or maintain quality of life and exercise capacity in this patient population. Patients undergoing liver transplantation seem to benefit from prehabilitation as well. Not only does it seem safe and feasible, but significant improvements in aerobic and functional capacity have also been found. Regarding heart transplant candidates, both inpatient and outpatient, supervised prehabilitation programs show promising results with improvements in exercise capacities and quality of life., Summary: Prehabilitation is an effective and safe intervention for improving functional outcomes of solid organ transplant patients. Future studies should evaluate whether prehabilitation translates into improved pre- and post-transplant clinical outcomes., Competing Interests: Conflict of InterestThe authors declare no competing interests., (© The Author(s) 2023.)

Background and Objectives: To date, employment figures of kidney transplant recipients in Europe are inconsistent. Additionally, little is known about work functioning of employed kidney transplant recipients and work functioning trajectories before and after transplantation., Design, Setting, Participants, & Measurements: Data from the ongoing TransplantLines Biobank and Cohort study and from community-dwelling employed adults were used. Health-related work functioning of kidney transplant recipients was assessed with the Work Role Functioning Questionnaire 2.0 and compared with potential kidney donors and community-dwelling employed adults., Results: We included 668 kidney transplant recipients of working age (59% men, age 51±11 years) at median 3 (interquartile range, 2-10) years after transplantation, 246 potential kidney donors of working age (43% men, age 53±9 years), and 553 community-dwelling employed adults (70% men, age 45±11 years). The proportion of employed kidney transplant recipients was lower compared with potential kidney donors (56% versus 79%). If employed, the work functioning score of kidney transplant recipients was slightly lower compared with employed potential kidney donors yet higher compared with community-dwelling employed adults (medians 91 [interquartile range, 76-98], 94 [interquartile range, 85-99], and 88 [interquartile range, 79-95], respectively). Backward linear regression analyses revealed that lower educational level, having a kidney from a deceased donor, presence of tingling or numbness of hands or feet, presence of concentration/memory problems, presence of anxiety, and presence of severe fatigue were independently associated with lower work functioning among kidney transplant recipients. Additional subgroup analyses showed that work functioning scores were lower before transplantation than at 12 months after transplantation (83 [interquartile range, 66-93] versus 92 [interquartile range, 88-98], respectively; P =0.002)., Conclusions: Stable employed kidney transplant recipients report to function well at work. In addition, this study shows that self-reported work functioning is higher after successful kidney transplantation compared with before transplantation., Clinical Trial Registry Name and Registration Number: TransplantLines Biobank and Cohort study, NCT03272841 PODCAST: This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2022&#95;09&#95;26&#95;CJN05560522.mp3., (Copyright © 2022 by the American Society of Nephrology.)

Impaired interplay between sensory and motor function may be an important, often overlooked cause of the decreased daily functioning and impaired health-related quality of life (HRQoL) of kidney transplant recipients (KTR). We assessed this interplay using a hand dexterity test, and investigated its potential associations with daily functioning and HRQoL among KTR enrolled at the TransplantLines Biobank and Cohort Study. A total of 309 KTR (58% male, mean age 56 ± 13 years) at median 4 [IQR: 1-11] years after transplantation were included. Impaired hand dexterity, as defined by a test performance slower than the 95th percentile of an age- and sex-specific reference population, was observed in 71 (23%) KTR. Worse hand dexterity was independently associated with worse performance on almost all measures of physical capacity, activities of daily living and societal participation. Finally, hand dexterity was independently associated with physical HRQoL (standardized beta - 0.22, 95%CI - 0.34 to - 0.09, P < 0.001). In conclusion, impaired interplay between sensory and motor function, as assessed by hand dexterity, is prevalent among KTR. In addition, poor hand dexterity was associated with impaired daily functioning and limited physical HRQoL. Impaired interplay between sensory and motor function may be therefore an important, hitherto overlooked, phenomenon in KTR., (© 2022. The Author(s).)

Background and Objectives: Many kidney transplant recipients suffer from fatigue and poor health-related quality of life. Airflow limitation may be an underappreciated comorbidity among kidney transplant recipients, which could contribute to fatigue and lower health-related quality of life in this population. In this study, we compared the prevalence of airflow limitation between kidney transplant recipients and healthy controls and investigated associations of airflow limitation with fatigue and health-related quality of life in kidney transplant recipients., Design, Setting, Participants, & Measurements: Data from the ongoing TransplantLines Biobank and Cohort study were used. Airflow limitation was defined as forced exhaled volume in 1 second less than the fifth percentile of the general population. Fatigue and health-related quality of life were assessed using checklist individual strength 20 revised (CIS20-R) and Short Form-36 (SF-36) questionnaires., Results: A total of 539 kidney transplant recipients (58% men; mean age 56±13 years) and 244 healthy controls (45% men; mean age 57±10 years) were included. Prevalence of airflow limitation was higher in kidney transplant recipients than in healthy controls (133 [25%] versus 25 [10%]). In multinomial regression models, airflow limitation was independently associated with fatigue severity (odds ratio moderate fatigue, 1.68; 95% confidence interval, 0.92 to 3.09 and odds ratio severe fatigue, 2.51; 95% confidence interval, 1.39 to 4.55; P =0.007) and lower physical health-related quality of life (-0.11 SDs; 95% confidence interval, -0.19 to -0.02; P =0.01) in kidney transplant recipients. In exploratory mediation analyses, fatigue accounted for 79% of the association of airflow limitation with physical health-related quality of life., Conclusions: Airflow limitation is common among kidney transplant recipients. Its occurrence is associated with more than two times higher risk of severe fatigue, and it is associated with lower physical health-related quality of life. Mediation analyses suggest that airflow limitation causes fatigue, which in turn, decreases physical health-related quality of life., Clinical Trial Registry Name and Registration Number: TransplantLines: The Transplantation Biobank, NCT03272841 PODCAST: This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2021&#95;11&#95;08&#95;CJN06600521.mp3., (Copyright © 2021 by the American Society of Nephrology.)

Background: Diarrhea is a well-known side effect of mycophenolic acid (MPA) use in kidney transplant recipients (KTRs). It is unknown whether self-reported diarrhea using the Modified Transplant Symptom Occurrence and Symptom Distress Scale (MTSOSD-59R) corresponds to stool water content and how both relate to MPA usage., Methods: MTSOSD-59R questionnaires filled out by 700 KTRs from the TransplantLines Biobank and Cohort Study (NCT03272841) were analyzed and compared with stool water content. Stool samples (N = 345) were freeze-dried, and a water content ≥80% was considered diarrhea., Results: Self-perceived diarrhea was reported by 46%, while stool water content ≥80% was present in 23% of KTRs. MPA use was not associated with self-perceived diarrhea (odds ratio(OR) 1.32; 95% confidence interval(CI), 0.87-1.99, p = .2), while it was associated with stool water content ≥80% (OR 2.88; 95%CI, 1.41-5.89, p = .004), independent of potential confounders. Adjustment for prior MPA discontinuation because of severe diarrhea, uncovered an association between MPA use and self-perceived diarrhea (OR 1.80; 95%CI, 1.13-2.89, p = .01)., Conclusions: These results suggest that reporting bias could add to the discrepancy between both methods for diarrhea assessment. We recommend use of objective biomarkers or more extensive questionnaires which assess information on stool frequency and stool consistency, to investigate post-transplantation diarrhea., (© 2021 The Authors. Clinical Transplantation published by John Wiley & Sons Ltd.)

Frailty is a multidimensional condition and is the result of the body's age-associated decline in physical, cognitive, physiological, and immune reserves. The aim of this systematic review is to assess the quality of evidence of the included studies, determine the prevalence of frailty among kidney transplant candidates, and evaluate the relationship between frailty and associated patient characteristics and outcomes after kidney transplantation., Methods: A systematic search was performed for relevant literature on frailty and kidney transplantation. This was followed by a meta-analysis for patient characteristics and outcomes reported by a minimum of 2 studies including mean age, gender, mean body mass index, type of kidney transplantation, dialysis, previous kidney transplantation, comorbidities, hypertension, race, preemptive kidney transplantation, delayed graft function, and length of stay., Results: A total of 18 studies were included in the systematic review and 14 of those studies were suitable for meta-analysis. The overall pooled prevalence of frailty before transplantation was estimated at 17.1% (95% confidence interval [CI], 15.4-18.7). Frailty was significantly associated with higher age (mean difference, 3.6; 95% CI, 1.4-5.9), lower rate of preemptive transplantation (relative risk, 0.60; 95% CI, 0.4-0.9), longer duration of delayed graft function (relative risk, 1.80; 95% CI, 1.1-3.0), and length of stay longer than 2 wk (odds ratio, 1.64; 95% CI, 1.2-2.3)., Conclusions: One in 6 kidney transplant recipients is frail before transplantation. The presence of frailty is associated with lower rates of preemptive transplantation, older recipient age, higher rates of delayed graft function, and longer length of stay. Future research is required to explore the association of frailty with other adverse outcomes after kidney transplantation and the effects of intervention programs to improve the different frailty domains., Competing Interests: The authors declare no funding or conflicts of interest., (Copyright © 2021 The Author(s). Transplantation Direct. Published by Wolters Kluwer Health, Inc.)

Objectives: Patient-reported outcome measures (PROMs) are widely applied to assess perceived health status. To date, no transplant-specific PROM is available for generating a single, standardized score regarding the health status of transplant recipients. The objective of this study is to generate health items for a new patient-centered PROM for organ recipients: the Transplant PROM (TXP)., Study Design and Setting: A five-phase, mixed-method approach was applied to identify and select the health items: scoping literature review, expert meetings, focus-group meetings with organ recipients, a special judgmental task within an online survey, and expert meetings for final selection of health items., Results: Based on a previously published scoping literature review, a first round of expert meetings, and a total of four focus-group meetings with kidney, lung, and liver transplant recipients (N = 18), a list of 83 relevant health items relating to post-transplant life was selected. In an online survey, 183 transplant recipients selected the 10 most important health items from this list. After evaluating the frequency of selected health items and combining items that assess closely related or similar concepts in the second round of expert meetings, nine health items were chosen to be included in TXP: fatigue, skin, worry/anxiety, self-reliance, activities, weight, sexuality, stooling, and memory/concentration., Conclusion: The nine TXP health items reflect the most prominent issues transplant recipients experience. The TXP can be administered by means of a mobile phone app., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

Introduction: In the past decades, short-term results after solid organ transplantation have markedly improved. Disappointingly, this has not been accompanied by parallel improvements in long-term outcomes after transplantation. To improve graft and recipient outcomes, identification of potentially modifiable risk factors and development of biomarkers are required. We provide the rationale and design of a large prospective cohort study of solid organ transplant recipients (TransplantLines)., Methods and Analysis: TransplantLines is designed as a single-centre, prospective cohort study and biobank including all different types of solid organ transplant recipients as well as living organ donors. Data will be collected from transplant candidates before transplantation, during transplantation, at 3 months, 6 months, 1 year, 2 years and 5 years, and subsequently every 5 years after transplantation. Data from living organ donors will be collected before donation, during donation, at 3 months, 1 year and 5 years after donation, and subsequently every 5 years. The primary outcomes are mortality and graft failure. The secondary outcomes will be cause-specific mortality, cause-specific graft failure and rejection. The tertiary outcomes will be other health problems, including diabetes, obesity, hypertension, hypercholesterolaemia and cardiovascular disease, and disturbances that relate to quality of life, that is, physical and psychological functioning, including quality of sleep, and neurological problems such as tremor and polyneuropathy., Ethics and Dissemination: Ethical approval has been obtained from the relevant local ethics committee. The TransplantLines cohort study is designed to deliver pioneering insights into transplantation and donation outcomes. The study design allows comprehensive data collection on perioperative care, nutrition, social and psychological functioning, and biochemical parameters. This may provide a rationale for future intervention strategies to more individualised, patient-centred transplant care and individualisation of treatment., Trial Registration Number: NCT03272841., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: The aims of the study were to examine whether distinct trajectories of anxious and depressive symptoms are present among liver transplant recipients from before transplantation to 2 years afterward, to identify associated demographic, clinical, and individual characteristics, and to examine the influence of distinct trajectories on outcomes., Methods: A prospective, multicenter cohort study was performed among 153 liver transplant recipients. Data were retrieved using questionnaires administered before transplantation and at 3, 6, 12, and 24 months after transplantation. Clinical data were retrieved by medical record review. Latent class growth analysis was used to identify distinct trajectories. χ test, analyses of variance, and multinomial logistic regression were used to identify associated variables and the impact of the distinct trajectories on outcomes., Results: Three distinct trajectories for symptoms of anxiety (State-Trait Anxiety Inventory-short form) as well as depression (Center for Epidemiological Studies Depression Scale) were identified: "no symptoms," "resolved symptoms," and "persistent symptoms." The trajectories of persistent anxiety and depression comprised, respectively, 23% and 29% of the transplant recipients. Several clinical and individual variables were associated with the trajectories of persistent anxiety and/or depression: experiencing more adverse effects of the immunosuppressive medication, lower level of personal control, more use of emotion-focused coping, less disclosure about the transplant, and more stressful life events. The trajectories of persistent symptoms were associated with worse outcomes regarding medication adherence and health-related quality of life, but not with mortality., Conclusions: A significant subset of transplant recipients showed persistent symptoms of anxiety and depression from before to 2 years after transplantation. These results emphasize the importance of psychosocial care in the transplant population.

Objectives: To explore whether distinct trajectories of anxiety and depression exist among liver transplant candidates, and to gain insight into demographic, clinical, and individual characteristics related with these trajectories., Design: A multicentre, prospective cohort study among 216 liver transplant candidates. Respondents filled out a questionnaire at study entrance and subsequently every 6 months until transplantation or removal from the waiting list., Methods: Anxiety (STAI6), depression (CES-D), demographic, and individual variables were assessed by questionnaire. Clinical variables were retrieved by medical record review. The SAS PROC TRAJ procedure was used to identify distinct trajectories. Univariate and multiple ordinal logistic regression analyses were used to explore related variables., Results: Regarding anxiety, three stable trajectories were identified as follows: below clinical level (51%), slightly above clinical level (34%), and high above clinical level (15%). Regarding depression, four stable trajectories were identified as follows: below clinical level (23%), slightly below clinical level (34%), slightly above clinical level (28%), and high above clinical level (6%). For anxiety as well as for depression, experiencing more liver disease symptoms, a lower level of personal control, making more use of emotional coping, and making less use of task-oriented coping increased the likelihood of membership in those trajectories with higher symptom levels., Conclusion: Distinct, but stable, trajectories of anxiety and depression were present in liver transplant candidates. The trajectories with symptom levels above clinical relevant levels for anxiety or depression comprised, respectively, 49% and 34% of the respondents. Therefore, psychological screening and subsequently providing appropriate interventions are warranted early in the transplant process. Statement of contribution What is already known on this subject For transplant candidates, the waiting-list period is a period of uncertainty and unpredictability. Psychological problems, such as anxiety and depression, are common among liver transplant candidates. Several demographic, clinical, and individual characteristics are associated with anxiety and depression, but these results remain inconclusive. What does this study add Distinct trajectories of symptoms of anxiety and depression are present among liver transplant candidates. Given the stability of the trajectories over time, the symptom level at baseline is indicative of the symptom level during the waiting-list period. Experiencing more liver disease symptoms, low mastery, more use of emotional coping, and less use of task-oriented coping are associated with trajectories of high symptom levels., (© 2017 The British Psychological Society.)

Objective: This study aimed at increasing the understanding of posttraumatic stress disorder (PTSD) in liver transplant patients by describing the course of PTSD, symptom occurrence, psychological co-morbidity, and the nature of re-experiencing symptoms., Methods: A prospective cohort study was performed among 95 liver transplant recipients from before transplantation up until one year post-transplantation. Respondents filled out a questionnaire regarding psychological functioning (PTSD, anxiety, and depression) before, and at 3, 6, and 12months post-transplantation. Both quantitative and qualitative methods were used to analyze the data., Results: Before transplantation, respectively 10.5% and 6.3% of the respondents were identified as possible cases of full or partial PTSD. In all cases, co-morbid conditions of anxiety and/or depression were present. After transplantation, no new onset of full PTSD was found. New onset of possible partial PTSD was found in six respondents. Arousal symptoms were the most frequently reported symptoms, but may not be distinctive for PTSD in transplant patients because of the overlap with disease- and treatment-related symptoms. Re-experiencing symptoms before transplantation were mostly related to waiting for a donor organ and the upcoming surgery; after transplantation this was related to aspects of the hospital stay., Conclusions: In our group of liver transplant patients, PTSD symptomatology was more present before transplantation than after transplantation. Being diagnosed with a life-threatening disease seemed to be the main stressor. However, when a diagnosis of PTSD is suspected, assessment by a clinician is warranted because of the overlap with mood and anxiety disorders, and disease- and treatment-related symptoms., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: In the Netherlands, anonymity of organ donation, which is currently protected by legislation, has come under discussion. In the Dutch society, a tendency to allow direct contact between transplant recipients and their donor's family is noticeable. As little is known about the opinion of Dutch liver transplant recipients on anonymity of organ donation and direct contact with the donor's family, this study examines their opinions., Methods: A cross-sectional study was conducted in 244 liver transplant recipients. Their opinions were examined in relation to demographic, transplant-related and emotional variables. Data were collected by questionnaire. Transplant-related variables were retrieved from the hospital's liver transplant database., Results: Fifty-three percent of the respondents (n = 177) agreed with anonymity of organ donation, mainly out of respect for the donor. Living situation, age, and level of positive affect influenced this opinion. The majority of the respondents (65%) indicated that they would like to receive some information about their donor, like age, sex, and health status. Only 19% of the respondents favored direct contact with the donor's family, mainly to express their gratitude personally. Respondents transplanted for alcoholic cirrhosis were less in favor of direct contact. Respondents with feelings of guilt doubted more about direct contact., Conclusion: There is no need to change the current legislation on anonymity of organ donation. However, most liver transplant recipients would like to receive some general information about their donor. Therefore, clear guidelines on the sharing of donor data with recipients need to be established.

After liver transplantation, recipients often experience psychological problems that are influenced by demographic, personal, and transplant-related variables. However, because previous studies have mostly reported on psychological problems and their influencing factors in the first years after transplantation, less is known about their prevalence and influence in the long run. The aims of this study were to examine point-prevalence rates of symptoms of anxiety, depression, and posttraumatic stress (PTS) at different time periods after transplantation and to examine the transplant-related variables associated with these problems. A cross-sectional survey was performed among 373 liver transplant recipients who received transplants between 1979 and 2009 at our center. Five clinically relevant time periods were identified: 0.5 to <2 years, 2 to <5 years, 5 to <10 years, 10 to <15 years, and ≥15 years after transplantation. The response rate was 75% (n=281). Overall, 33.4% of the respondents experienced clinically relevant symptom levels of anxiety (28.7%), depression (16.5%), or PTS (10.0%). Symptoms of anxiety and depression were more prevalent in the first 2 years and in the long term after transplantation. PTS symptoms were more prevalent in the first 5 years after transplantation. However, the prevalence rates did not differ significantly between time periods. Viral hepatitis and the number of side effects of the immunosuppressive (IS) medication were found to be associated with all psychological problems. Alcoholic liver disease was associated with anxiety and depression in the short term after transplantation. In conclusion, a significant subset of transplant recipients experience psychological problems, both shortly after transplantation and in the long run. These problems are often associated with side effects from the IS medication. Therefore, the monitoring of psychological problems, the offering of psychological counseling, and the management of the medication's side effects should be part of the routine care of transplant recipients., (© 2015 American Association for the Study of Liver Diseases.)

At the time of the organ offer for transplantation, donor-related risks such as disease transmission and graft failure are weighed against the patient's risk of remaining on the waiting list. The patient's commonly inactive role in decision making and the timing and extent of donor-specific risk information have been discussed in the medical literature. This is the first study revealing the opinions of liver patients on these issues. Forty patients listed for liver transplantation and 179 liver transplant patients participated in an anonymous questionnaire-based survey. The majority of the patients wanted to be informed about donor-related risks (59.8%-74.8%). The preferred timing for being informed about donor-related risks was the time of the organ offer for 53.3% of the patients. Among these patients, 79.8% wished to be involved in making the decision to accept or not accept a liver for transplantation, 10.6% wished to make the final decision alone, and only 9.6% did not want to be involved in the decision-making process. Implementing this knowledge through the standardization of the content, the manner of transfer, and the amount of information that we provide to our patients will improve opportunities for shared decision making at different time points during the transplant allocation process. This will enable us to provide the same opportunities and care to every patient on the waiting list., (© 2014 American Association for the Study of Liver Diseases.)

Aims and Objectives: To compare a functioning assessment based on the International Classification of Functioning, Disability and Health (ICF) with a conventional medical assessment, in terms of their respective consequences for health professionals' clinical decision-making and the fit with patient's own perspective of health., Background: In chronic diseases, pathogenic-oriented health care falls short in generating all the information required for determining healthcare provision to improve health. A broader, so-called salutogenic approach, by using the ICF, focusing on how to stay healthy, rather than on what causes diseases, seems more appropriate., Design: A cross-sectional comparative study using data from a randomised controlled trial., Methods: Data about patient problems and professional healthcare activities were collected from a total of 81 patients with severe multiple sclerosis who were randomly assigned to one of two groups: the ICF group, assessed with a functioning assessment (n = 43), and the medical group, assessed with a conventional medical assessment (n = 38). Data were analysed statistically using descriptive and inferential statistics., Results: A functioning assessment resulted in the registration of significantly more patient problems in the health components 'participation' and 'environmental factors', as well as significantly more professional healthcare activities befitting these components. The ICF group had a significant positive correlation between registered problems by health professionals and patients' self-reported problems, whereas the medical group had several negative correlations., Conclusion: A functioning assessment resulted in a care plan that not only was broader and more complete but also reflected the patients' self-reported problems more closely than a medical assessment, without a loss of focus on medical problems., Relevance to Clinical Practice: This study has shown that some health problems remain unnoticed by a medical assessment alone, which is especially important for the chronically ill. A functioning assessment provides a strong foundation for identifying all relevant information related to health., (© 2013 John Wiley & Sons Ltd.)

Little is known about the extent to which transplant recipients face emotional problems with the receipt of a transplanted organ. The Transplant Effects Questionnaire (TxEQ) enables the quantification of these problems. This study evaluates the psychometric properties of the Dutch translation of the TxEQ (TxEQ-NL) in a group of liver transplant recipients. Confirmatory factor analyses of the TxEQ-NL revealed an adequate fit with the original version. However, four items showed factor loadings <.40. Internal consistency was acceptable (.66-.79). The small correlations between the TxEQ-NL and generic measures of psychological functioning indicated that the constructs measured are related but distinguishable. Therefore, the TxEQ-NL adds a new dimension to the measurement of psychological functioning of transplant recipients., (Copyright © 2013 Wiley Periodicals, Inc.)

Background: Case management has been suggested as an innovative strategy that facilitates the improvement of a patient's quality of life, reduction of hospital length of stay, optimization of self-care and improvement of satisfaction of patients and professionals involved. However, there is little evidence about the effectiveness of the patient advocacy case management model in clinical practice.Therefore, the objective of our study was to examine the effects of the Dutch patient advocacy case management model for severely disabled Multiple Sclerosis (MS) patients and their caregivers compared to usual care., Methods/design: In this randomized controlled trial the effectiveness of casemanagement on quality of life of patients and their caregivers, quality of care, service use and economic aspects were evaluated. The primary outcomes of this study were quality of life of MS-patients and caregiver burden of caregivers.Furthermore, we examined quality of life of caregivers, quality of care, service use and costs., Discussion: This is a unique trial in which we examined the effectiveness of case management from a broad perspective. We meticulously prepared this study and applied important features and created important conditions for both intervention and research protocol to increase the likelihood of finding evidence for the effectiveness of patient advocacy case management. Concerning the intervention we anticipated to five important conditions: 1) the contrast between the case management intervention compared to the usual care seems to be large enough to detect intervention effects; 2) we included patients with complex care situations and/or were at risk for critical situations; 3) the case managers were familiar with disease specific health-problems and a broad spectrum of solutions; 4) case managers were competent and authorized to perform a medical neurological examination and worked closely with neurologists specialized in MS; and 5) the case managers had a regional network of professionals and health care organisations at their disposal, and were accepted as a coordinator of care. We also put a lot of effort on the selection of eligible patients, randomization and statistical methods, but also on power analysis, selection of reliable, validated and sensitive outcome measures, and (statistical) control of confounders., Trial Registration: Dutch Trial Register http://www.trialregister.nl. Trial ID: NTR762.

Objective: Despite efforts to improve outcomes in heart failure (HF), readmission rates remain relatively high. Reasons for readmission from different perspectives (patient, caregiver, health care providers) may help to optimize the future management of patients with HF. The aims of this study are to 1) gain insight into reasons for HF readmission from the perspective of patients, caregivers, cardiologists, and HF nurses; 2) examine similarities and differences in perspectives on the reason for an HF readmission, and 3) describe possibilities to prevent an HF readmission from different perspectives., Methods and Results: Data on reasons for readmission were collected on 173 readmissions. Perspectives of patients, caregivers, cardiologists, and HF nurses were collected by interview and questionnaire. Worsening HF as the sole reason for readmission was reported most often; however, 36% of caregivers, 56% of patients, and 63% to 65% of health care providers indicated that other factors, such as comorbidity, nonadherence, and nonoptimal medication, were important contributing factors. In only 34% of readmissions, patients and their caregivers agreed with health care providers on the underlying reason. Respondents reported that 23% to 31% of the readmissions could probably have been prevented if adherence were higher, patients requested help earlier, and adequate multidisciplinary professional help were available., Conclusion: To prevent future readmissions of patients with HF, it is important to fully understand the reasons for readmission by gaining insight on the reason for readmission from different perspectives. Also, we may need another approach to prevent adverse outcomes in which other medical problems and new strategies to improve adherence have to be considered.

The management of patients with heart failure (HF) is complex and often benefits from a patient-tailored approach. Since the early 1990s, HF disease management programs have been developed and implemented to improve outcomes of patients with HF. The body of evidence of the effectiveness of these programs is still growing, but meta-analyses of disease management program studies show various results on outcomes. This raises questions regarding the optimal organizational structure and components of a most cost-effective HF management program. Case management has been described as a solution to improve outcomes in complex patients and as a possible link to effective disease management. This raises the question of what case management can add to the disease management of patients with HF and which patients might benefit. The aim of this article is to discuss the potential contribution of case management in the disease management of patients with HF.