Bakgrund: Väntelistorna för de patienter som står i kö för en levertransplantation blir allt längre i alla länder runt om i världen. Väntetiden upplevs för patienterna som en psykiskt och socialt påfrestande tid eftersom det är oklart om och när ett organ som passar blir tillgängligt. Det är viktigt att sjuksköterskan antar utmaningen att möta lidandet och den lidande människan och bidra till att minska detta. Syfte: Syftet med litteraturstudien var att belysa och beskriva patienters upplevelser i väntan på en levertransplantation. Metod: Litteraturstudien bygger på totalt 10 kvalitativa och kvantitativa vetenskapliga artiklar. Resultat: Att bli uppsatt på väntelistan för en ny lever upplevdes av många patienter som en enorm lättnad och de fick en känsla av hopp samtidigt som det innebar en fysisk och psykisk begränsning i tillvaron. Rädsla och ångest på grund av ovissheten var också ett stort problem för deltagarna. Informationen och stödet ansågs vara viktigt under väntetiden. Diskussion: Upplevelsen av förändrad självbild och identitet, ångest samt behovet av information och stöd i väntan diskuterades och kopplades samman med Joyce Travelbees omvårdnadsteori samt sjuksköterskans kompetens. Slutsats: För att kunna utveckla omvårdnaden kring patienter som väntar på en levertransplantation krävs det mer forskning som belyser upplevelsen av väntan före en levertransplantation. / Background: The number of patients on waiting lists for a liver transplant is growing in all countries around the world. These patients experience the waiting as a psychologically and socially stressful time, because it is unclear if and when a suitable organ will become available. It is important for the nurse to try to relieve the suffering of these patients. Aim: The purpose of this study was to illustrate and describe patients' experiences while waiting for a liver transplant. Method: This literature study was based on a total of ten articles describing research performed using qualitative and quantitative methods. Results: Being put on the transplant waiting list gave the patients feelings of substantial relief and hope, but at the same time involved physical and mental limitations in their daily lives. Fear and anxiety due to the uncertainty of the situation was also a significant problem for the liver candidates. Information and support was regarded as important during the waiting time. Discussion: The experiences of a changed self-image and identity, anxiety, and the need for information and support were discussed and linked to Joyce Travelbee’s nursing theory and to the skills of nurses. Conclusion: To be able to develop nursing care related to cases involving liver transplants, more research is needed to highlight the things the patients experience while waiting to undergo such surgery.

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Each year, 800 people wait for an organ transplant in Sweden. The development of drugs for organ rejection has evolved over the past 60 years, which has increased the survival of patients who have undergone organ transplantation. The most common organ transplanted is the kidney, liver, lung and heart. There are more studies done on quality of life after an organ transplant, but very few studies on quality of life before organ transplantation. The aim of the study was to describe the experiences of quality of life among patients waiting for an organ transplant. A literature overview of eight articles was analyzed in both similarities and differences. The articles were published between 2002 and 2012. The result is presented in four themes, hope of life, living in uncertainty, the body fails and need for support. In some of the themes subthemes were found. Most themes affected quality of life in a negative way. Stress and anxiety were two factors that many patients described as a cause of low quality of life. Many patients described the waiting time as living in uncertainty. Various disease symptoms showed differently depending on the underlying disease. Results showed that patients waiting for an organ transplant have a low quality of life but only a few studies showed that these patients, despite their disease, could feel joy.

Sjuksköterskan bör ha kunskap om begreppet livskvalitet för att kunna bemöta patienter som genomgått en levertransplantation, då den upplevda livskvalitén är betydelsefull för patienterna. Syftet var att beskriva livskvalitet hos patienter som genomgått en levertransplantation. Studien är genomförd som en litteraturstudie där 12 vetenskapliga artiklar har granskats. Resultatet visar att den upplevda livskvalitén hos levertransplanterade patienter är relativt god men det finns delar av livskvalitén som påverkas negativt efter levertransplantationen. Livskvalitén påverkas av fysiska, psykiska och sociala aspekter. De delar som påverkade livskvalitén positivt var familjen, att kunna återvända till det yrkesverksamma livet och att få en chans till ett nytt liv. Negativa aspekter som framkom i resultatet var bland annat förlorad autonomi, fysisk inaktivitet och en känsla av utanförskap i samhället. Vidare omvårdnadsforskning inom området livskvalitet relaterat till levertransplantation bör utföras. Sjuksköterskor behöver utbildning i ämnet för att i omvårdnadsarbetet kunna främja och bevara patienters livskvalitet. / The nurse should have knowledge of the concept of quality of life to respond to patients who underwent a liver transplant, when the perceived quality of life is important for patients. The aim was to describe the quality of life in patients undergoing a liver transplant. The study was conducted as a literature review of 12 scientific papers that have been reviewed. The results show that the perceived quality of life in liver transplant patients is relatively good but there are elements of quality of life adversely affected by post-liver transplant. Quality of life is affected by physical, psychological and social aspects. The elements affecting the quality of life positively were the family, ability to return to the working life and to get a chance to start a new life. Negative aspects that emerged from the results included the loss of autonomy, physical inactivity and a sense of alienation in society. In addition, nursing research in the field of quality of life related to liver transplantation should be performed. Nurses need education on the topic of the nursing work to promote and preserve patients' quality of life.

INTRODUCTION: Preoperative pulmonary rehabilitation (PPR) is an emerging therapy for transplant candidates who are awaiting surgery. Research indicates that PPR training has benefits for improving exercise tolerance, but little researcher exists on the association between PPR on post-transplant hospital outcomes. METHODS: The study was a non-probability cross-sectional analysis performed on data for post-transplant recipients who received either a single or bilateral lung transplant from February 8, 2007 to July 8, 2014. The study sample consisted of 207 transplant recipients. Analyses of the associations between independent variables: preoperative pulmonary rehabilitation and six-minute walk distance (6MWD) and covariates were performed by logistic regression analysis to examine the following outcomes: length of stay, hospital readmissions in the first 90 days post- transplant, and the number of hospital readmissions in the first 90 days. RESULTS: Transplant recipients who participated in preoperative pulmonary rehabilitation had 1.77 times greater odds of being readmitted in the first 90 days post-transplant compared to recipients who did not participated in preoperative pulmonary rehabilitation. Transplant recipients whose 6MWD was greater than 207 meters and who participated in preoperative pulmonary rehabilitation had 4.99 times greater odds of length of staying 12 days or less post- transplant surgery compared to transplant recipients whose walk distance was less than 207 meters and who did not participate in preoperative pulmonary rehabilitation. CONCLUSION: Pulmonary rehabilitation is an important part of the lung transplant. The results of this study indicate the importance of preoperative lung transplant on post-transplant outcomes for transplant recipients.

The use of lung transplantation, a life saving intervention, has been increasing over the last thirty years with a disappointing median survival of only 4.8 years. Despite the progress made in immunosuppressive therapies, allograft rejection following transplantation is the leading cause of death. As part of the immunosuppressive therapy, mycophenolate mofetil (MMF), the ester prodrug of mycophenolic acid (MPA) has proven its efficacy among heart, liver, kidney as well as lung transplanted patients. However, due to its rapid excretion, high daily doses are necessary and lead to serious side effects, forcing the patient to stop and change their course of treatment. Administration of drugs to the lungs is known to minimize local and systemic side effects by employing a lower amount of drug, to increase patient compliance and to improve the efficacy of the treatment. Therefore, developing novel MMF formulations for targeted delivery to the lungs will broaden the therapeutic options against lung transplant rejection. Within the framework of this dissertation, the development of an inhaled formulation of MMF was investigated. MMF must be metabolized by carboxylesterases to become active and its metabolism suffers from high inter- and intra-patient variability. The first objective of this dissertation was to investigate the occurrence of MMF hydrolysis in the lung. The second objective was to study the in vivo deposition,metabolism and distribution in rats, of an inhaled micron-size MMF suspension in comparison to inhaled IV Cellcept® and oral Cellcept®, the currently marketed products. According to the in vitro results, MMF is metabolized in human lung cells by carboxylesterases. The in vivo results showed an incomplete metabolism of MMF when delivered as a suspension due to the limited dissolution of the drug in the lungs. Following inhalation, the MMF suspension achieved higher and more prolonged concentration of the total drug in the lungs and lymphoid tissues as compared to the inhaled IV Cellcept®. The pulmonary delivery of the MMF suspension was able to achieve similar levels of drug in the lungs, higher levels in the lymphoid tissues and significantly lower levels in the systemic circulation when compared to the levels obtained from the oral gavage of oral Cellcept®. Ultimately, this dissertation demonstrated that the administration of micron-size MMF suspension offers a great potential for pulmonary administration. / text

El objetivo de nuestro estudio fue evaluar si el fallo de la función intestinal absortiva observado después del trasplante de intestino delgado se debe a cambios en el tamaño de la superficie epitelial o bien proviene de un fallo en la función celular de los enterocitos. MATERIAL Y MÉTODOSSe realizaron trasplantes de intestino delgado (SBT) en ratas de acuerdo con la técnica de Monchik y Russell. Los animales fueron distribuidos en tres grupos (n=15 cada uno): Grupo A (control): asa simple de Thiry Vella; Grupo B: isotransplante heterotópico LEW-LEW; Grupo C: alotransplante heterotópico LBN-LEW. Se utilizó como solución de preservación Ringer lactato heparinizado a 4º C. Las ratas del grupo C se trataron con Ciclosporina (15mg/kg/24h IM). A los 21 dias del transplante heterotòpico, en 5 animales de cada grupo se realizó un segundo procedimiento quirúrgico para colocar el segmento de intestino transplantado en posición ortotópica. Mediante microscopía òptica y tinción H/E se observó la evolución micromorfológica de la mucosa intestinal, tomando muestras del intestino donante in situ antes de la perfusión y tras el transplante a los 7,14,21 y 36 dias. Estas muestras fueron procesadas mediante un sistema de analisis morfométrico de imagenes para quantificar cambios en el tamaño de las vellosidades en cuanto altura y anchura y asi determinar una posible modificacion en la superficie epitelial absortiva. En las series con transplante ortotópico, las muestras de intestino se estudiaron además por Microscopía Electrónica de Transmisión (TEM). Para determinar la evolución de la función absortiva del intestino transplantado se efectuaron pruebas de absorción de glucosa en los mismos intervalos de tiempo que las biopsias.RESULTADOS El estudio morfométrico muestra una disminución progresiva en la altura de las vellosidades tras el transplante, siendo más pronunciado en el grupo C. Una tendencia al aumento se observó en el ancho de las vellosidades. La superficie epitelial absortiva mostró una tendencia a la reducción, recuperando los valores iniciales tras la interposición ortotópica. Una reducción progresiva significativa de la absorción de glucosa se observó en ambos grupos de animales trasplantados respecto al grupo control. El estudio por TEM mostró la presencia de vacuolas citoplasmáticas en los enterocitos, así como una leve alteración en la morfología de las microvellosidades, mitocondrias y retículo endoplásmico. DISCUSIÓN Y CONCLUSIONES Una alteración de la fisiología celular parece ser la causa del fallo de la función de absorción intestinal después de SBT y este fracaso no dependería del tamaño de la superficie epitelial. Las alteraciones ultraestructurales observadas al TEM sugieren un daño celular grave que podría ser la causa de la insuficiencia absortiva. Pero el origen de estas alteraciones intracelulares sigue siendo desconocido pudiendo provenir tanto del efecto isquemia-reperfusión como de la respuesta inmunológica o de la toxicidad del propio tratamiento inmunosupresor. / The aim of our study was to asses if the failure of the absortive intestinal function observed after small bowel transplantation is due either to changes in the size of epithelial surface or caused by a failure in the cellular function of enterocytes.MATERIALS AND METHODSSmall bowel transplants (SBT) were performed in rats according to Monchik and Russell's technique. Animals were distributed into three groups (n=15 each):Group A (control):simple Thiry-Vella loop; Group B:heterotopic isograft LEW-LEW; Group C:heterotopic allograft LBN-LEW. Heparinized lactated Ringer's at 4ºC was a cold preservation solution. Cyclosporine dose 15mg/kg/24h IM was administered to group C rats. At day 21 of the initial surgery, a second operative procedure was carried out on 5 of the transplanted animals of each group to place the transplanted small bowel in orthotopic position.To asses the micromorphology of intestinal mucosa by light microscopy (LM), biopsy specimens of the donor small bowel were taken in situ before perfusion and after transplant at 7,14,21 and 36 days. In those series with orthotopic transplantation bowel samples were studied, in addition, by Transmision Electron Microscopy (TEM).The absortive function of the transplanted bowel was observed by Glucose absorption test performed at same time points of the biopsies. Histomorphometric determinations of size of villus height and width, and total epithelial surface was performed by LM H/E and Image Processing and Analysis System.RESULTSMorphometrical study shows a progressive shortening of villus in both groups of transplanted animals, being more pronounced in the group C at the end of study. A tendency to increase was observed in the villus width. The absorptive epithelial surface showed an initial reduction followed of return to normal state after orthotopical interposition.A significative progressive reduction of glucose absorption was observed in both groups of transplanted animals than in the control group.Study by TEM showed cytoplasmic vacuoles in the absorptive cells. There was also a slight alteration on morphology of microvilli, mitochondries and endoplasmic reticulum.DISCUSSION/CONCLUSIONSAn alteration of cellular physiology underlies the failure of intestinal absorptive function after SBT and this failure does not depend on the size of epithelial surface. The findings of TEM suggest a severe ultrastructural damage could be the cause of cellular absorptive failure, but the cause of this cellular damage remains unkown.

Objective: The aim of this study was to determine the role of race as a significant risk factor for prediction of outcomes in heart failure (HF). Methods: The data was collected on demographics, detailed history of HF, family history, vital signs, medication and laboratory profile for 585 patients from Heart failure Treatment Center of Emory University after year of 2000. Outcome of HF was defined as combination of death, placement of left ventricular assisted devise, heart transplant or emergency transplant. The independent relationship between race and outcomes of HF was evaluated by univariate and multivariate logistic regression analyses. The survival analysis was done by Cox regression modeling. Results: Among 585 HF patients, 58.1% were whites and 41.9% were blacks and 28.2% HF patients had positive outcomes. Although Whites tended to have a more positive outcome (34.6%) than blacks (28.9%), the difference was not statistically significant. Factors predicting the outcome in whites were male gender (OR 5.02), history of hypertension (OR 2.3), ventricular arrhythmias (OR 2.4), placement of AICD(OR 0.09), low EF% (OR 0.95), high NYHA class (OR 3.25), use of beta blockers (OR 0.12), aldosterone blockers (OR 2.19), furosemide (2.18); while in blacks they were age in years (OR 0.96), history of PTCA (OR 7.04), dislipidemia (OR 3.90), depression (OR 0.01), placement of AICD (OR 0.14), low EF% (OR 0.92), systolic blood pressure (OR 0.96), high NYHA class (OR 4.01), use of beta blockers (OR 0.14), torsemide (OR 2.86), and digoxin (OR 4.91) etc. Blacks had higher survival than whites (p < 0.001). Conclusion: There is no significant difference in combined outcome (death, transplant, emergency transplant, and Left Ventricular Assisted Devise placement) of HF between whites and blacks. There are differences regarding the risk factors, which are more prominent in each race. Further exploration is required to evaluate the race as significant risk factor for predicting the outcome in HF.

This thesis investigates the role of Canadians in the international trade in human organs and the factors influencing patient decision making, assuming that patients make decisions regarding the management of their illness in a complex social, cultural, political and economic nexus. It engages a broad theoretical question of whether Canadians uphold values consistent with a commitment to consumerism, commodifying organs as needed and afforded, or altruism, supportive of voluntary organ donation systems. Semi-structured interviews were conducted with hemodialysis patients and their care givers in a southern Ontario hospital. Based on this analysis, Canadians appear to fall somewhere in the middle of the consumer-altruist divide. The dominant sentiment among participants was that Canadians ought not to be commodified, but the organs of foreign others in places removed from the Canadian value system hold potential, and provide opportunities for participating in a market when the supply of organs falls short of demand.

Our epidemiology research found that the incident and prevalent rates for Diabetes mellitus (DM) and Diabetic End Stage Renal Disease (DM-ESRD) were at rise in Saskatchewan between year 1980 and 2005. Combining concerns regarding the rising trends reported by research studies with the concerns of the significant health and financial burden imposed by DM-ESRD on individuals and societies, we sought to project the number of DM-ESRD patients in Saskatchewan up to year 2025 with the cost required for caring for those patients. An agent-based model (ABM) is developed to simulate DM to ESRD progression, treatments for DM-ESRD patients, and the assessments and waiting list processes preparing patients for kidney transplants. The model parameters were estimated from a wide variety of data sources. The agent based modeling approach is chosen for projections regarding the DM-ESRD situation in Saskatchewan because of its advantage in capturing heterogeneities of individual patients, ability to retain biographical information on patients, capacity to capture time-varying competing risks, better presentations features and easy integration with existing models built in either agent based or System Dynamic methods. The approach was also attractive due to its flexibility for future expansion to represent social networks. The model projects the incident and prevalent case count, cost, and person years lived for the DM-ESRD population in Saskatchewan between year 1980 and 2025. The projections captured the great challenges brought by the fast growing number of DM-ESRD patients and substantial cost associated with managing the disease. In addition to producing projection results, the research presented here demonstrates how the model can be used by policy makers to experiment and evaluate different policy/interventions in a safe context. By capturing both the individual level records and population level statistics, the model provide a wealth of data for detailed analysis, which can help health policy makers gain insights in the current and future diabetic-ESRD situation in the province, aiding in resources planning for managing the fast-growing ESRD population and the growing need for dialysis services.