Background: Studies evaluating the possible health-promoting effects of sound nutrition in heart and lung transplant recipients are currently lacking. Despite advances in drug treatment and patient monitoring, lifestyle-associated complications such as obesity, diabetes and cardiovascular disease occur frequently. Following transplantation, a low-fat eating pattern is currently viewed as best standard care. However, a Mediterranean diet based on a varied range of fresh unprocessed foods and supplemented with extra virgin olive oil has demonstrated clinical benefit in various non-transplant populations. The aim of this study was to evaluate the feasibility and acceptability of a Mediterranean vs a low-fat diet intervention in heart and lung transplant recipients, and to assess clinical and biochemical outcomes. Methods: This was a randomised controlled feasibility trial to evaluate a Mediterranean diet supplemented with extra-virgin olive oil, vs a modified low-fat diet in heart and lung transplant recipients at a single centre. In total, 41 clinically stable male and female (median age 55 years) transplant recipients were randomly assigned (1:1) in two separate 12-month waves (n=24 and n=17) to one of these diet interventions. A range of validated food frequency and adherence questionnaires captured changes in participants' reported eating habits to 6 weeks post-study. Clinical and biochemical analysis was conducted at baseline, 25 and 52 weeks. Telephone and outpatient contact provided a support mechanism to reinforce dietary behavioural change. Caloric intake and physical exercise awareness were discussed, but not promoted. Results: Thirty nine participants completed the trial (95%). Adherence to both interventions improved significantly at week 25, and was maintained at 52 and 58 weeks. Compared with baseline, waist circumference decreased in both groups at week 25 (p=0.024). A decrease in blood pressure and heart rate occurred at 52 weeks in the low-fat group only. At 52 weeks, higher adherence resulted in significant improvements in fasting glucose in the Mediterranean (< 4.8%) and low-fat (< 5%) groups. This respective pattern was also observed with total cholesterol (≤ 9% and ≤ 7%), triglycerides (≤ 9% and ≤ 20%) and IGF-1 (≤ 9% and ≤ 15%). A significant decrease in the LDL/HDL ratio (≤ 12%) occurred in the Mediterranean group only. Moreover, clinically relevant lipid and glucose regulation changes were observed in each intervention. Conclusions: The implementation of a prospective 12-month Mediterranean or low-fat diet is feasible and acceptable in a heart and lung transplant outpatient setting. Both interventions were positively associated with improvements in lipid and blood glucose regulation and circulating IGF-1. As part of a multidisciplinary framework, these findings offer an additional therapeutic strategy to optimise outpatient care.

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People who need a liver transplant must choose a hospital at which the transplant will be performed. The United Network for Organ Sharing (UNOS) allocates organs to patients based on patient characteristics and assumes all hospitals have equal skill. The question for a patient thus becomes, which hospital to choose? This thesis investigates whether the differences in liver transplant survival rates for hospitals are a result of differences in patients and/or differences in hospital-specific criteria. The findings in this thesis show that most of the differences in hospital survival rates are due to patient characteristics, and that, while not conclusive, hospital characteristics may have an impact on survival rates. However, the variable that is most significant to survival rates is the cold ischemic time, or transportation time of the organ. These results suggest that policies to allocate organs nationally are not optimal. / Master of Arts

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Class of 2012 Abstract / Specific Aims: To compare and evaluate the therapies prescribed, the incidence of adverse drug events, and the time to clinical cure in transplant patients with a cytomegalovirus (CMV) infection at an academic medical center before and during the foscarnet nationwide shortage. Methods: This study was a retrospective chart review to compare CMV treatment prescribed and clinical outcomes in pediatric and adult transplant patients at an academic medical center. Transplant patients were evaluated over a 16 month time period between December 2009 and March 2011. The average dose (mg/kg) and prevalence ganciclovir, foscarnet, and cidofovir prescribed in transplant patients with CMV infection were evaluated. Additionally, the incidence of adverse drug events including acute renal dysfunction and myelosuppression were characterized. Main Results: There were 30 subjects diagnosed with CMV disease during the evalutaion period. Of all of the patients treated for CMV before the shortage, 79% received ganciclovir, 43% received foscarnet, and 21% received cidofovir. Following the shortage in September 2010, the usage of the antiviral agents changed to 100%, 25%, and 13% respectively. Overall the usage of ganciclovir increased while the usage of foscarnet decreased when there was a shortage of medication. Conclusions: The antiviral prescribing patterns changed significantly during the foscarnet shortage. The average dose and incidence of ganciclovir increased which likely contributed to serious adverse events. Due to the limited amount of patients treated for CMV and the short time frame, clinical cure could not be determined at this time. Drug shortages are a serious problem and significantly influence patient outcomes.