Old Age and Frailty in Deceased Organ Transplantation and Allocation-A Plea for Geriatric Assessment and Prehabilitation

Prehabilitation in surgery - an update with a focus on nutrition

PURPOSE OF REVIEW

Since the introduction of the prehabilitation concept for optimizing functional capacity before surgery 20 years ago, evidence and interest has grown considerably. This review summarizes the recent evidence and proposes questions for prehabilitation with special regard to the nutritional component.

RECENT FINDINGS

Several meta-analyses of multimodal prehabilitation (exercise, nutrition, and psychological support) have been published recently. These reviews suggest that preoperative conditioning can improve functional capacity and reduce the complication rate for many patient groups (risk of bias: moderate to low). A prerequisite is the identification of high-risk patients using suitable screening and assessment tools. Additionally, there are currently no standardized, clear recommendations for the organization and implementation of prehabilitation programs. The programs vary greatly in duration, content, and outcome measurement. Although the preoperative nutrition interventions enhanced outcomes consistently, there was no clear evidence for which nutritional intervention should be applied to whom over consistent time frame four to six weeks (timeframe consistent with most prehabilitation programs).

SUMMARY

To advance our understanding of which prehabilitation interventions work best, how they work, and for whom they work best, additional low risk of bias and adequately powered trials are required. Nevertheless, our review presents evidence that prehabilitation should be offered before major surgery on a risk-stratified basis.

Comprehensive Geriatric Assessment (CGA) and Optimisation Services in Older Kidney Patients: Results from the First UK-Wide Transplant Centre and Renal Unit Survey Study

Background: Demand for renal replacement therapy (including dialysis, transplantation and supportive care) in patients over 60 is increasing. Concerns regarding poorer outcomes and decision-making in this cohort have been raised. Evidence suggests these relate to frailty, multimorbidity and cognitive impairment, all seen frequently in older age. Comprehensive Geriatric Assessment (CGA) is a multidisciplinary methodology proven to improve outcomes relating to this triad and could be transformative for older kidney patients. This national UK survey aims to describe (1) attitudes/beliefs of renal physicians and transplant surgeons in the UK toward the CGA for older potential kidney transplant recipients and those being considered for dialysis or supportive care; (2) provision of CGA services for these patients in the UK; (3) barriers and enablers to the provision of these CGA services in the UK. Methods: The UK's 72 renal units (RUs) and 23 adult kidney transplant centres (TCs) were invited to complete online surveys electronically using a protected link (24 April 2024-31 August 2024). Results: The response rate was 100%. Only six RUs offered CGA services. However, respondents overwhelmingly advocated CGA for older patients being considered for transplant (RUs 47/55, TCs 17/19), dialysis (RUs 52/54) and supportive care (RUs 51/54). Lack of funding to support CGA-OS (45/51), lack of available staff to deliver CGA (44/51) and time constraints (36/51) were reported barriers to implementing CGA by RUs. TCs identified lack of funding (13/18) and published evidence (12/18) as the main barriers. Conclusions: Transplant surgeons and renal physicians alike support CGA for older kidney patients, but only six UK units currently offer the service to these patients. Research developing and implementing CGA for this population is essential to optimise outcomes and influence policy at the national level.

Kidney Transplant Candidacy: Addressing Common Medical and Psychosocial Barriers to Transplant

Improving access to kidney transplants remains a priority for the transplant community. However, many medical, psychosocial, geographic, and socioeconomic barriers exist that prevent or delay transplantation for candidates with certain conditions. There is a lack of consensus regarding how to best approach many of these issues and barriers, leading to heterogeneity in transplant centers' management and acceptance practices for a variety of pretransplant candidate issues. In this review, we address several of the more common contemporary patient medical and psychosocial barriers frequently encountered by transplant programs. The barriers discussed here include kidney transplant candidates with obesity, older age, prior malignancy, cardiovascular disease, history of nonadherence, and cannabis use. Improving understanding of how to best address these specific issues can empower referring providers, transplant programs, and patients to address these issues as necessary to progress toward eventual successful transplantation.

Non-Donors of Organs and Tissues Due to Medical Refusal in a Transplant Referral Service

BACKGROUND

Obtaining organs for transplants through a deceased donor occurs exclusively through donation. However, some open protocols with potential donors do not become effective donors due to medical refusal. Our aim was to identify the profile of non-donors of organs and tissues due to medical refusal in a state reference service for transplants.

METHODS

This is a cross-sectional study with retrospective data collection from medical records of patients who died and had a protocol opened to evaluate brain death and procurement of organs and tissues in 2019.

RESULTS

The sample consisted of 27 patients, the majority of whom were female, aged over 71 years, had primary education, and were married. The main causes of medical refusal were age above the recommended age and septicemia. Brain death was mostly confirmed within 12 hours, and the main cause of hospitalization was a vascular event.

CONCLUSIONS

Identifying the profile of non-donors due to medical refusal is necessary for services to identify possible misattributed medical contraindications and thus contribute to reducing the disproportion between supply and demand for organs and tissues for transplants.

Effects of predictive nursing interventions on pressure ulcer in elderly bedridden patients

The study explores the impact of predictive nursing interventions on pressure ulcers (PUs) in elderly bedridden patients. A total of 120 elderly bedridden patients from the Central Hospital of Enshi Tujia and Miao Autonomous Prefecture between August 2019 and August 2023 were selected as the subjects of the study and were randomly divided into an observation group and a control group using a random number table method. The control group received conventional nursing care, while the observation group received predictive nursing interventions. The study compared the incidence of PUs, Braden scale scores, the onset time of PUs, self-rating anxiety scale (SAS) scores, self-rating depression scale (SDS) scores, and nursing satisfaction between the two groups. In elderly bedridden patients, the application of predictive nursing interventions significantly reduced the incidence of PUs (p < 0.001), significantly lowered the SAS and SDS scores (p < 0.001), and also significantly increased Braden scale scores (p < 0.001) and delayed the onset time of PUs (p < 0.001). Additionally, it improved patients' nursing satisfaction (p = 0.008). Predictive nursing interventions in elderly bedridden patients have good application effects, reducing the occurrence of PUs, delaying the time of onset in patients, improving patients' negative emotions and enhancing nursing satisfaction rates. It is worthy of widespread use.