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Martin DE, Harris DCH, Jha V, Segantini L, Demme RA, Le TH, McCann L, Sands JM, Vong G, Wolpe PR, Fontana M, London GM, Vanderhaegen B, Vanholder R. Ethical challenges in nephrology: a call for action. Nat Rev Nephrol 2020; 16:603-613. [PMID: 32587403 DOI: 10.1038/s41581-020-0295-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2020] [Indexed: 12/14/2022]
Abstract
The American Society of Nephrology, the European Renal Association-European Dialysis and Transplant Association and the International Society of Nephrology Joint Working Group on Ethical Issues in Nephrology have identified ten broad areas of ethical concern as priority challenges that require collaborative action. Here, we describe these challenges - equity in access to kidney failure care, avoiding futile dialysis, reducing dialysis costs, shared decision-making in kidney failure care, living donor risk evaluation and decision-making, priority setting in kidney disease prevention and care, the ethical implications of genetic kidney diseases, responsible advocacy for kidney health and management of conflicts of interest - with the aim of highlighting the need for ethical analysis of specific issues, as well as for the development of tools and training to support clinicians who treat patients with kidney disease in practising ethically and contributing to ethical policy-making.
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Affiliation(s)
- Dominique E Martin
- School of Medicine, Deakin University, Geelong Waurn Ponds Campus, Geelong, VIC, Australia.
| | - David C H Harris
- University of Sydney at Westmead Hospital, Westmead, NSW, Australia
| | - Vivekanand Jha
- George Institute for Global Health, UNSW, New Delhi, India
- University of Oxford, Oxford, UK
- Manipal Academy of Higher Education, Manipal, India
| | - Luca Segantini
- International Society of Nephrology, Brussels, Belgium
- European Society for Organ Transplantation - ESOT c/o ESOT, Padova, Italy
| | - Richard A Demme
- Renal Division and Department of Medical Humanities and Bioethics, University of Rochester School of Medicine, Rochester, NY, USA
| | - Thu H Le
- Nephrology Division, Department of Medicine, University of Rochester School of Medicine, Rochester, NY, USA
| | - Laura McCann
- American Society of Nephrology, Washington, DC, USA
| | - Jeff M Sands
- Renal Division, Emory University School of Medicine, Atlanta, GA, USA
| | - Gerard Vong
- Center for Ethics, Emory University, Atlanta, GA, USA
| | | | - Monica Fontana
- European Renal Association - European Dialysis and Transplant Association, Parma, Italy
| | - Gerard M London
- Manhes Hospital, Nephrology Department GEPIR, Fleury-Mérogis, France
| | | | - Raymond Vanholder
- Nephrology Section, Department of Internal Medicine and Pediatrics, University Hospital, Corneel Heymanslaan 10, B9000, Gent, Belgium
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Nakazawa E, Yamamoto K, Akabayashi A, Shaw MH, Demme RA, Akabayashi A. Will you give my kidney back? Organ restitution in living-related kidney transplantation: ethical analyses. J Med Ethics 2020; 46:144-150. [PMID: 31537615 PMCID: PMC7035681 DOI: 10.1136/medethics-2019-105507] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 09/04/2019] [Accepted: 09/08/2019] [Indexed: 06/10/2023]
Abstract
In this article, we perform a thought experiment about living donor kidney transplantation. If a living kidney donor becomes in need of renal replacement treatment due to dysfunction of the remaining kidney after donation, can the donor ask the recipient to give back the kidney that had been donated? We call this problem organ restitution and discussed it from the ethical viewpoint. Living organ transplantation is a kind of 'designated donation' and subsequently has a contract-like character. First, assuming a case in which original donor (A) wishes the return of the organ which had been transplanted into B, and the original recipient (B) agrees, organ restitution will be permissible based on contract-like agreement. However, careful and detailed consideration is necessary to determine whether this leaves no room to question the authenticity of B's consent. Second, if B offers to give back the organ to A, then B's act is a supererogatory act, and is praiseworthy and meritorious. Such an offer is a matter of virtue, not obligation. Third, if A wishes B to return the organ, but B does not wish/allow this to happen, it is likely difficult to justify returning the organ to A by violating B's right to bodily integrity. But B's refusal to return the donated organ cannot be deemed praiseworthy, because B forgets the great kindness once received from A. Rather than calling this an obligation, we encourage B to consider such virtuous conduct.
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Affiliation(s)
- Eisuke Nakazawa
- Department of Biomedical Ethics, Faculty of Medicine, The University of Tokyo, Bunkyo, Tokyo, Japan
| | - Keiichiro Yamamoto
- Department of Biomedical Ethics, Faculty of Medicine, The University of Tokyo, Bunkyo, Tokyo, Japan
| | - Aru Akabayashi
- Department of Biomedical Ethics, Faculty of Medicine, The University of Tokyo, Bunkyo, Tokyo, Japan
| | - Margie H Shaw
- Division of Medical Humanities and Bioethics, University of Rochester Medical Center, Rochester, New York, USA
| | - Richard A Demme
- Division of Medical Humanities and Bioethics, University of Rochester Medical Center, Rochester, New York, USA
| | - Akira Akabayashi
- Department of Biomedical Ethics, Faculty of Medicine, The University of Tokyo, Bunkyo, Tokyo, Japan
- Division of Medical Ethics, New York University School of Medicine, New York, New York, USA
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Abstract
Introduction: There is considerable variation in brain death understanding and policies between medical institutions, however, studies have not yet compared different health-care professionals working in the same hospital. Research Questions: The overall aim of this study was to evaluate understanding of brain death among health-care professionals within intensive care units (ICUs) at a single institution. Design: Study participants included 217 attending physicians, residents, nurses, medical students, and other ICU team members in 6 ICUs. Participants completed a 21-question survey pertaining to knowledge of brain death and related institutional policies as well as opinions about brain death. Results: We found a wide range of brain death understanding among health-care professionals in ICUs. Attending physicians have the greatest understanding (94.7%), followed by nurses (72.4%). In contrast, approximately half of the students and residents do not have a basic understanding of brain death. Brain death understanding was correlated to health-care role, years of experience, and whether the participant had formal training in brain death. Although most participants had been involved in cases of brain death, a much smaller number had received formal training on death by neurological criteria. Discussion: The present study observed a paucity of clinical training in brain death among health-care professionals in the study ICUs. There is an opportunity for improved clinical education on brain death that could improve communication with families about brain death and potentially increase the number of organs transplanted.
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Affiliation(s)
- Michelle M. Lawson
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Christopher J. Mooney
- Department of Medical Humanities and Bioethics, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Richard A. Demme
- Department of Medical Humanities and Bioethics, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
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Nakazawa E, Maeda S, Yamamoto K, Akabayashi A, Uetake Y, Shaw MH, Demme RA, Akabayashi A. Reuse of cardiac organs in transplantation: an ethical analysis. BMC Med Ethics 2018; 19:77. [PMID: 30119629 PMCID: PMC6098651 DOI: 10.1186/s12910-018-0316-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 08/01/2018] [Indexed: 11/20/2022] Open
Abstract
Background This paper examines the ethical aspects of organ transplant surgery in which a donor heart is transplanted from a first recipient, following determination of death by neurologic criteria, to a second recipient. Retransplantation in this sense differs from that in which one recipient undergoes repeat heart transplantation of a newly donated organ, and is thus referred to here as “reuse cardiac organ transplantation.” Methods Medical, legal, and ethical analysis, with a main focus on ethical analysis. Results From the medical perspective, it is critical to ensure the quality and safety of reused organs, but we lack sufficient empirical data pertaining to medical risk. From the legal perspective, a comparative examination of laws in the United States and Japan affirms no illegality, but legal scholars disagree on the appropriate analysis of the issues, including whether or not property rights apply to transplanted organs. Ethical arguments supporting the reuse of organs include the analogous nature of donation to gifts, the value of donations as inheritance property, and the public property theory as it pertains to organs. Meanwhile, ethical arguments such as those that address organ recycling and identity issues challenge organ reuse. Conclusion We conclude that organ reuse is not only ethically permissible, but even ethically desirable. Furthermore, we suggest changes to be implemented in the informed consent process prior to organ transplantation. The organ transplant community worldwide should engage in wider and deeper discussions, in hopes that such efforts will lead to the timely preparation of guidelines to implement reuse cardiac organ transplantation as well as reuse transplantation of other organs such as kidney and liver.
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Affiliation(s)
- Eisuke Nakazawa
- Department of Biomedical Ethics, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Shoichi Maeda
- Course for Health Care Management, Graduate School of Health Management/Department of Health Policy and Management, School of Medicine, Keio University, Kanagawa, Fujisawa, 252-0883, Japan
| | - Keiichiro Yamamoto
- Department of Biomedical Ethics, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Aru Akabayashi
- Department of Biomedical Ethics, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Yuzaburo Uetake
- Department of Biomedical Ethics, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Margie H Shaw
- Division of Medical Humanities and Bioethics, University of Rochester Medical Center, Rochester, NY, USA
| | - Richard A Demme
- Division of Medical Humanities and Bioethics, University of Rochester Medical Center, Rochester, NY, USA
| | - Akira Akabayashi
- Department of Biomedical Ethics, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan. .,Division of Medical Ethics, New York University School of Medicine, New York, NY, USA.
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Akabayashi A, Nakazawa E, Ozeki-Hayashi R, Tomiyama K, Mori K, Demme RA, Akabayashi A. Twenty Years After Enactment of the Organ Transplant Law in Japan: Why Are There Still So Few Deceased Donors? Transplant Proc 2018; 50:1209-1219. [PMID: 29880339 DOI: 10.1016/j.transproceed.2018.02.078] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 01/12/2018] [Accepted: 02/06/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Twenty years have passed since the 1997 enactment of the Organ Transplant Law in Japan, but the number of deceased donors remains extremely low. In this study we examine why deceased donation has continued to remain so infrequent. METHODS This investigation was a secondary analysis of published data from the Japan Organ Transplant Network, 2016 Fact Book of Organ Transplantation in Japan, and International Registry on Organ Donation and Transplantation. RESULTS In the past 20 years, donation intent declarations, knowledge, and respect for family member's wishes have increased, whereas resistance toward transplantation has decreased. Despite this, the traditional perspective on corpses of gotai manzoku (ie, the soul cannot be put to rest without being physically intact and without defect), the family-centricism, and reward-seeking altruism have not changed much. Living organ transplants have alleviated the organ deficiency somewhat, and the law requiring family consent seems to have contributed to the observed small increase in deceased donors. CONCLUSION The number of deceased donors is unlikely to increase suddenly. However, 8 strategies are proposed to increase the number of deceased donors, including: increasing the number of donor procurement coordinators and establishing a training system; increasing the number of organ procurement facilities; creating hub transplant centers and training transplant surgeons; implementing radical reform in public education; reducing workload and improving education of emergency physicians, neurosurgeons, and pediatricians; revisiting the stringent standards of brain-death determination; revisiting the registration process; and considering development of a Japanese version of organ procurement organizations as well as revisions to the Organ Transplant Law. The Japanese government and academic societies must work together to increase the number of deceased donors in Japan.
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Affiliation(s)
- A Akabayashi
- Department of Biomedical Ethics, Faculty of Medicine, University of Tokyo, Tokyo, Japan
| | - E Nakazawa
- Department of Biomedical Ethics, Faculty of Medicine, University of Tokyo, Tokyo, Japan
| | - R Ozeki-Hayashi
- Department of Biomedical Ethics, Faculty of Medicine, University of Tokyo, Tokyo, Japan
| | - K Tomiyama
- Division of Abdominal Transplant Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - K Mori
- Department of Biomedical Ethics, Faculty of Medicine, University of Tokyo, Tokyo, Japan
| | - R A Demme
- Division of Medical Humanities and Bioethics, University of Rochester Medical Center, Rochester, New York
| | - A Akabayashi
- Department of Biomedical Ethics, Faculty of Medicine, University of Tokyo, Tokyo, Japan.
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Parajuli S, Singh J, Sandal S, Liebman SE, Demme RA. Self-Reported Employment Status and Social Participation After Successful Kidney Transplantation. Prog Transplant 2016; 26:92-8. [PMID: 27136255 DOI: 10.1177/1526924816633956] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction: Kidney transplantation (KTX) is considered the treatment of choice for most individuals with end-stage kidney disease. The purpose of this study was to assess the employment status and social participation after successful KTX. Methods: This was a retrospective cross-sectional study. Eligible participants were patients who received a transplant ≥1 year ago and who were previously on hemodialysis (HD) for ≥1 year. Two hundred individuals participated in this study. Results: A significant number (93.5%) of patients reported they were working prior to HD versus 35% while on HD. Only 14% reported receiving disability benefits prior to HD versus 75% receiving disability while on HD. Comparing transplant recipients with pre-HD patients, 35.5% versus 93.5% reported working, and 74.5% versus 14% reported receiving disability benefits, respectively. After transplant, patients were more likely to join recreational clubs, travel frequently, and participate in recreational/religious activities and social events than when they were on HD. Conclusion: Posttransplant, these individuals are more likely to participate in social and leisure activities, but the majority did not resume employment and continued to receive disability payments. Future studies could explore barriers to employment in patients who underwent successful transplantation and the causes and factors as to why these individuals continue to receive disability benefits.
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Affiliation(s)
- Sandesh Parajuli
- University of Rochester Medical Center, Rochester, NY, USA
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Jagmeet Singh
- University of Rochester Medical Center, Rochester, NY, USA
- Guthrie Robert Packer Hospital, Sayre, PA, USA
| | - Shaifali Sandal
- University of Rochester Medical Center, Rochester, NY, USA
- McGill University Health Centre, Montreal, QC, Canada
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Reid TT, Demme RA, Quill TE. When there are no good choices: illuminating the borderland between proportionate palliative sedation and palliative sedation to unconsciousness. Pain Manag 2014; 1:31-40. [PMID: 24654583 DOI: 10.2217/pmt.10.1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Despite state-of-the-art palliative care, some patients will require proportionate palliative sedation as a last-resort option to relieve intolerable suffering at the end of life. In this practice, progressively increasing amounts of sedation are provided until the target suffering is sufficiently relieved. Uncertainty and debate arise when this practice approaches palliative sedation to unconsciousness (PSU), especially when unconsciousness is specifically intended or when the target symptoms are more existential than physical. METHODS We constructed a case series designed to highlight some of the common approaches and challenges associated with PSU and the more aggressive end of the spectrum of proportionate palliative sedation as retrospectively identified by palliative care consultants over the past 5 years from a busy inpatient palliative care service at a tertiary medical center in Rochester (NY, USA). RESULTS Ten cases were identified as challenging by the palliative care attendings, of which four were selected for presentation for illustrative purposes because they touched on central issues including loss of capacity, the role of existential suffering, the complexity of clinical intention, the role of an institutional policy and use of anesthetics as sedative agents. Two other cases were selected focusing on responses to two special situations: a request for PSU that was rejected; and anticipatory planning for total sedation in the future. CONCLUSION Although relatively rare, PSU and more aggressive end-of-the-spectrum proportionate palliative sedation represent responses to some of the most challenging cases faced by palliative care clinicians. These complex cases clearly require open communication and collaboration among caregivers, patients and family. Knowing how to identify these circumstances, and how to approach these interventions of last resort are critical skills for practitioners who take care of patients at the end of life.
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Affiliation(s)
- Thomas T Reid
- University of California, 533 Parnassus Avenue, Box 0903, Suite U154, San Francisco, CA 94143-0903, USA
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Kahn SA, Demme RA, Lentz CW. Mortality after treating severe burns with traditional Amish home remedies: A case report, literature review and ethical discussion. Burns 2013; 39:e13-6. [DOI: 10.1016/j.burns.2012.09.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Accepted: 09/08/2012] [Indexed: 01/22/2023]
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Nickels MW, Cullen JP, Demme RA, Vetter M, Boulay R, Betts R, McKee M, Orloff M, Bozorgzadeh A. A psychosocial evaluation process for living liver donors: the University of Rochester model. Int J Psychiatry Med 2012; 41:295-308. [PMID: 22238836 DOI: 10.2190/pm.41.4.a] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE The donation of livers by living donors entails complex processes, both surgically and psychosocially, potentially involving risks in both domains. Thorough psychosocial evaluation is necessary to minimize those risks, yet little has been written about the donor assessment process. This article describes one such process, utilized by a transplant program in upstate New York. METHOD Donor candidates undergo multiple psychosocial interviews early in the overall transplant evaluation process. Evaluators subsequently meet as a group, along with an independent ethicist, to determine psychosocial candidacy prior to final medical/surgical clearance. RESULTS Between 2003 and 2007, 416 donor candidates initiated and/or underwent full evaluation, resulting in a 17.5% surgery and 55.5% exclusion rate among those individuals. Of those ruled out, 20.8% were for (medical or psychosocial) reasons associated with the recipient, and 8.7% were for donor-related psychosocial issues. CONCLUSION Given the primacy ofpsychosocial and ethical issues in living liver donor candidate evaluation, the multiple interview process, followed by team discussion and overseen by an ethicist removed from other transplant program functions, has advantages as a donor assessment model.
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Affiliation(s)
- M W Nickels
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York 14642, USA.
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Affiliation(s)
- Richard A Demme
- University of Rochester Medical Center, Center for Ethics, Humanities, and Palliative Care, 601 Elmwood Ave, Box 675, Rochester, NY 14642, USA.
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Abstract
Ethical concerns are common in palliative care settings. Rather than provide an exhaustive list of possible ethical problems one may come upon, this article describes areas of concern that are frequently encountered by perioperative health care providers, especially anesthesiologists, in the palliative care arena.
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Affiliation(s)
- Richard A Demme
- Nephrology Division, The Center for Palliative Care and Clinical Ethics, University of Rochester Medical Center, 601 Elmwood Avenue, Box 675, Rochester, NY 14624, USA.
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Shah A, Kendall G, Demme RA, Taylor J, Bozorgzadeh A, Orloff M, Jain A, Abt P, Zand MS. Home glucometer monitoring markedly improves diagnosis of post renal transplant diabetes mellitus in renal transplant recipients. Transplantation 2005; 80:775-81. [PMID: 16210964 DOI: 10.1097/01.tp.0000173769.09518.f1] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Definitions of de novo posttransplant diabetes mellitus (PTDM) have varied widely in the renal transplant literature, and most have not used the American Diabetes Association (ADA) definition of diabetes (fasting plasma glucose [FPG] > or = 126 mg/dl on two occasions, or a casual plasma glucose level >200 mg/dl). Most patients are monitored for PTDM by 12-hour FPG levels drawn for clinic visits. In contrast, we describe the diagnosis of PTDM by home glucometer monitoring METHODS We screened 89 consecutive nondiabetic renal transplant recipients for PTDM by ADA criteria and home glucometer monitoring during the first 3 months posttransplant RESULTS Of 23 patients with impaired fasting glucose levels of 111-126 mg/dl, 14 (61%) met ADA criteria for diabetes mellitus of based on home glucometer monitoring. The incidence of de novo PTDM was 31% during this period. Predictors of PTDM in a Cox proportional hazards model were race and acute rejection, with a trend towards BMI. Clinic visit FPG levels did not differ between PTDM and non-PTDM patients. All diagnoses were made based on prelunch or supper FPG >200 mg/dl. CONCLUSIONS Overnight FPG are inadequate for diagnosis of PTDM. All renal transplant recipients with impaired FPG should, at minimum, have home FPG testing.
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Affiliation(s)
- Amish Shah
- Division of Nephrology, Department of Medicine, University of Rochester Medical Center, Rochester, NY 14642, USA
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Demme RA. Truth and consequences in an era of "unsurance". Am J Bioeth 2004; 4:69-71. [PMID: 16192214 DOI: 10.1080/15265160490906826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
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Demme RA. Organs for undocumented aliens--another look: response to "Distributing American hearts for transplantation: the predicament of living in the global village" by Henry S. Perkins (CQ vol 4, no 2). Camb Q Healthc Ethics 1996; 5:281-3. [PMID: 8718736 DOI: 10.1017/s0963180100007040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- R A Demme
- Wilford Hall Medical Center, Lackland Air Force Base, Texas, USA
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Demme RA. Tiny Tim, Dickens, renal disease, and rickets. Am J Dis Child 1993; 147:819-21; author reply 820-1. [PMID: 8352213 DOI: 10.1001/archpedi.1993.02160320021010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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