Nahel Elias

ObjectiveMiscommunications can trigger unexpected adverse events following hospital discharge of medically complex patients. In this study, we evaluate the impact of a structured communication process between patients and their providers in the inpatient and outpatient settings to improve the quality and safety of organ transplantation after-care, specifically the hospital-to-home transition.MethodsWe conducted this prospective intervention study to determine the impact of an ambulatory hospital-to-home transition bundle on post-discharge quality and safety events and readmissions over a 2-year period. A multi-stakeholder team developed and implemented structured verbal and written tools anchored within the I-PASS® handoff framework to address gaps in coordination of discharge care. The study was implemented in two phases: first, addressing provider-to-provider communication, and second, addressing provider-to-patient communication. The primary outcome measure was the rate of 30-day post-discharge incidents collected from medical record review and post-discharge patients phone queries. Thirty-day post-discharge health care utilization data were measured as secondary outcomes.Results212 incidents were identified over the three study periods: 104 pre-intervention incidents, 70 post-phase 1 (1.60 vs. 0.88 incidents/discharge, p<0.001), and 38 post-phase 2 (1.60 vs 0.90 incidents/discharge, p<0.001). Categorized by harm and type: non-safety related quality events and follow-up appointments incidents decreased significantly (p<0.01) following both interventions. After the phase 2 intervention, preventable adverse events and medical test incidents decreased significantly (p<0.05 and p<0.01 respectively). Implementing the Phase 2 protocol was associated with a statistically significant 20.6% reduction in 30-day hospital readmissions (95% CI: –33.5% to –6.2%).ConclusionA novel post-discharge communication bundle was associated with a reduction in unexpected incidents and resource utilization for transplant patients following the transition from hospital-to-home. Practice Implications: Standardizing communication among all health team members, patients and families at discharge has significant potential to improve quality and safety of transitions after hospitalization.

People with HIV-1 have higher risk for rejection after kidney transplantation but the mechanism is poorly understood. As HIV latency promotes immune dysregulation and chronic inflammation, we evaluated whether the size of the HIV latent viral reservoir (LVR) at baseline and through 52-weeks is associated with rejection in kidney transplant recipients with HIV from donors with and without HIV. Using the intact proviral DNA assay, we found no differences in the LVR between those who experienced rejection (n = 14) versus those who did not (N = 55) regardless of donor HIV status. These data support the feasibility of HIV+ to HIV+ organ transplantation. Clinical Trials Registration. NCT03500315.

BACKGROUND: Transplanting kidneys from donors with HIV to recipients with HIV has become standard clinical practice. However, donors with HIV may have higher prevalence of viral and bacterial infections and autoimmunity that could increase allograft rejection in recipients. METHODS: We included deceased kidney donors (60 with HIV and 41 without HIV) who participated in a multicenter prospective study of HIV kidney transplantation between April 2018 and September 2021. Using phage immunoprecipitation sequencing, we compared the human antibody repertoire (allergens, autoantibodies, viruses, and bacterial toxins) between donors with and without HIV and evaluated their association with recipient allograft rejection. Moderated t tests were used to assess reactivity and a multivariate logistic regression model adjusted for donor sex and kidney donor profile index assessed the association between donor adenovirus reactivity and recipient allograft rejection. RESULTS: Compared with donors without HIV, donors with HIV had lower BMI and were more likely to be African American. The median number of positive autoantibodies was marginally higher among donors with HIV (499 [IQR, 357, 579]) compared with that of donors without HIV (395 [IQR, 256, 538], P = 0.058). Donors with HIV additionally had significantly higher antibody reactivity to Epstein-Barr virus and cytomegalovirus ( q < 0.05). Among all donors with and without HIV, antibodies against adenovirus were significantly associated with increased rejection among recipients, including after adjusting for false discovery ( q < 0.05) and also adjusting for demographic factors using multivariable logistic regression (odds ratio = 4.97; 95% CI = 1.89–13.61). CONCLUSION: The presence of antibodies against adenovirus infection in kidney donors with HIV may be associated with allograft rejection. TRIAL REGISTRATION: ClinicalTrials.gov NCT03500315. FUNDING: US NIH.

Background: Kidney transplantation (KT) from donors with human immunodeficiency virus (HIV-1) to recipients with HIV (HIV D+/R+) is noninferior to KT from donors without HIV (HIV D−/R+) with regard to safety. However, there may be differences in posttransplant infections. Methods: We performed a secondary analysis of the HOPE in Action KT Study (NCT02602262) comparing the time to first clinically relevant infection within 24 months posttransplantation in 99 HIV D+/R+ versus 99 HIV D−/R+. Secondary outcomes included incidence rates, infection-related death, and timing of clinically relevant infection, each stratified by donor HIV status. Results: The cumulative incidence of a clinically relevant infection at 24 months posttransplantation was 73.8% (95% confidence interval [CI]: 63.1%–81.2%) for HIV D+/R+ versus 64.7% (95% CI: 53.0%–73.4%) for HIV D−/R+. Comparing time to first clinically relevant infection in HIV D+/R+ versus HIV D−/R+, the adjusted hazard ratio (aHR) was 1.44 (95% CI: 1.01–2.04) at 24 months posttransplantation; for infections associated with hospitalization, the aHR was not significantly higher (1.21 [95% CI: .78–1.86). There were no significant differences in the number of infections, death from infection, duration, or site of infection between HIV D+/R+ versus HIV D−/R+, though viral infections were numerically more common in HIV D+/R+ (40% vs 35%). Conclusions: Although there was a statistically significant association between receipt of a kidney from a donor with HIV and time to first clinically relevant infection in the 24 months posttransplantation, there were no differences in infections associated with hospitalization. These data are overall reassuring as this emerging practice expands into clinical care. Clinical Trials Registration. NCT02602262.