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INTRODUCTION: Transplant providers must understand the definition of increased risk donor (IRD) organs to effectively educate transplant candidates and obtain informed consent. This study surveyed non-physician providers from 20 transplant centers about their educational and informed consent practices of IRD kidneys. METHODS: An anonymous, web-based survey about the content and timing of education and informed consent for potential recipients of IRD kidneys, providers' knowledge of IRD kidneys, and provider and center characteristics was completed by most (67%; 90 of 135) of those invited to participate; 87 responses were included in analysis. RESULTS: Most (80%) reported understanding the concept of IRD kidneys. However, few reported sufficient knowledge of the Organ Procurement and Transplantation Network definition of IRDs, risk factors, screening tests, window periods, and infection transmission rates. Most (56%) felt uncomfortable with obtaining specific informed consent for IRD kidneys. Most respondents received informal education about IRD kidneys (78%), and recognized the need for (98%) and were interested in receiving (99%) further education on this topic. CONCLUSION: Non-physician transplant providers need and are interested in better education about IRD kidneys to effectively educate patients and obtain patients' informed consent.

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BACKGROUND: Tuberculosis (TB) reactivation is a rare but significant complication of organ transplantation, and screening of all transplant candidates for latent infection is recommended with either an interferon-γ release assay (IGRA) or tuberculin skin test (TST). METHODS: After institutional review board approval, we retrospectively collected data to describe the yield of transplant candidate screening using the QuantiFERON-TB Gold (QFT) and QuantiFERON-TB Gold In-Tube (QFT-IT) assays since the institution of TB screening in 2008 and the epidemiology of all cases of post-transplant TB in our institution since 2004. RESULTS: A total of 2392 patients were screened with either the QFT or QFT-IT assay through October 2009; 245 (10.2%) tested positive and 206 (8.6%) were indeterminate. Of those with positive results, 107 (43.7%) were foreign born and most of the remainder had prior TB exposures. Of the tests performed at a reference lab, 29% were indeterminate, whereas 14% were indeterminate using our in-house lab. The majority of indeterminate results were seen in liver transplant candidates (40.6% vs. 11.8% in non-liver candidates). Three of 694 (0.43%) screened patients who underwent transplantation developed TB post transplant. CONCLUSIONS: Post-transplant TB occurs at a low rate with universal IGRA-based candidate screening, which is comparable to studies using TST screening.

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The Organ Procurement and Transplantation Network (OPTN) mandates that organ recipients provide "specific informed consent" before accepting organs that the OPTN defines as "increased risk". However, the OPTN does not provide specific guidelines for what information should be disclosed to potential recipients. Such vagueness opens the door to inadequate informed consent. This paper examines the ethical dimensions of informed consent when the prospective living donor has self-reported behaviors associated with increased risk for infection transmission. Donor privacy is a primary ethical concern that conflicts with recipients' informed consent for use of increased risk organs. We propose that both the increased risk status and the specific behavior be disclosed to the recipient. Because the actual risk posed is linked to the type of risk behavior, disclosure is therefore needed to make an informed decision. The donor's risk behavior is material to recipients' decision making because it may impact the donor-recipient relationship. This relationship is the foundation of the donation and acceptance transaction, and thus comprises a critical feature of the recipient's informed consent. Optimizing a recipient's informed consent is essential to protecting patient safety and autonomy.

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The role of the advanced practice nurse (APN) in transplantation has evolved from the role of the clinical transplant coordinator. This report attempts to define the credentials, practice domains, barriers to practice, and reimbursement issues related to APN practice while contrasting the role with that of clinical transplant coordinator. The nephrology APN working in a collaborative transplant practice can be an integral part of a multidisciplinary health care team. The APN's education and credentials empower them to provide a wider scope of services than transplant coordinators who are "experts by experience." These services can include providing primary care and performing procedures such as percutaneous transplant biopsies, insertion of peripheral and central venous catheters, and wound debridement as well as management of patients along their continuum of transplant care. Patient education and advocacy also are key components of APN practice. In addition, the services the APN provides generally are reimbursable and therefore can provide revenue for the practice.

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Due to concern over the morbidity and mortality associated with infections in transplant recipient patients, a review of the literature was completed to evaluate the risk of patients acquiring infection from pets and during travel and to improve teaching by transplant teams. There is a paucity of information in the literature regarding such infections in transplant patients, however, reviewing studies involving acquired immune deficiency syndrome (AIDS) patients yielded important data.

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Part II of the clinical outcome session dealt with treatment-specific issues as they relate to outcome. Ms. McNatt and Ms. Kleindienst described cardiovascular disease as it influences mortality and morbidity in organ transplant recipients. Ms. Hawkins outlined the impact of vascular access on patients undergoing hemodialysis treatment while Ms. Currier delineated the problem of infection in peritoneal dialysis treatment.

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Renal transplantation is often the preferred renal replacement modality for individuals with the complex problem of diabetic nephropathy. Referral to a transplant program before renal replacement therapy is needed allows patients an opportunity to make treatment decisions as well as offer the advantages of early transplantation. In addition to routine post-transplantation surveillance, health care after transplantation is directed towards prevention and management of diabetic sequelae.

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The National Kidney Foundation recently held four regional forums to discuss controversies in organ donation. All interested parties, both in the public and private sectors, were invited to submit written and oral testimony. The following is the written testimony submitted by ANNA and presented orally by Ms. McNatt at the regional forum in Chicago, April 9, 1992.

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