First name
Peter
Middle name
P
Last name
Reese

Title

Risk Factors for Increased Stent-Associated Symptoms Following Ureteroscopy for Urinary Stones: Results from STENTS.

Year of Publication

2023

Number of Pages

101097JU0000000000003183

Date Published

01/2023

ISSN Number

1527-3792

Abstract

PURPOSE: The STudy to Enhance uNderstanding of sTent-associated Symptoms (STENTS) sought to identify risk factors for pain and urinary symptoms, as well as how these symptoms interfere with daily activities after ureteroscopy for stone treatment.

MATERIALS AND METHODS: This prospective observational cohort study enrolled patients aged ≥12 years undergoing ureteroscopy with ureteral stent for stone treatment at 4 clinical centers. Participants reported symptoms at baseline; on postoperative days (POD) 1, 3, 5; at stent removal; and day 30 post-stent removal. Outcomes of pain intensity, pain interference, urinary symptoms, and bother were captured with multiple instruments. Multivariable analyses using mixed-effects linear regression models were identified characteristics associated with increased stent-associated symptoms (SAS).

RESULTS: A total of 424 participants were enrolled. Mean age was 49 years (SD 17); 47% were female. Participants experienced a marked increase in SAS on POD 1. While pain intensity decreased ∼50% from POD 1 to POD 5, interference due to pain remained persistently elevated. In multivariable analysis, older age was associated with lower pain intensity(p=0.004). Having chronic pain conditions(p<0.001), prior severe stent pain(p=0.021), and depressive symptoms at baseline(p<0.001) were each associated with higher pain intensity. Neither sex, stone location, ureteral access sheath use, nor stent characteristics were drivers of SAS.

CONCLUSIONS: In this multicenter cohort, interference persisted even as pain intensity decreased. Patient factors (e.g., age, depression) rather than surgical factors were associated with symptom intensity. These findings provide a foundation for patient-centered care and highlight potential targets for efforts to mitigate the burden of SAS.

DOI

10.1097/JU.0000000000003183

Alternate Title

J Urol

PMID

36648152

Title

Quality of life impact and recovery after ureteroscopy and stent insertion: insights from daily surveys in STENTS.

Year of Publication

2022

Number of Pages

53

Date Published

2022 Apr 06

ISSN Number

1471-2490

Abstract

<p><strong>BACKGROUND: </strong>Our objective was to describe day-to-day evolution and variations in patient-reported stent-associated symptoms (SAS) in the STudy to Enhance uNderstanding of sTent-associated Symptoms (STENTS), a prospective multicenter observational cohort study, using multiple instruments with conceptual overlap in various domains.</p>

<p><strong>METHODS: </strong>In a nested cohort of the STENTS study, the initial 40 participants having unilateral ureteroscopy (URS) and stent placement underwent daily assessment of self-reported measures using the Brief Pain Inventory short form, Patient-Reported Outcome Measurement Information System measures for pain severity and pain interference, the Urinary Score of the Ureteral Stent Symptom Questionnaire, and Symptoms of Lower Urinary Tract Dysfunction Research Network Symptom Index. Pain intensity, pain interference, urinary symptoms, and bother were obtained preoperatively, daily until stent removal, and at postoperative day (POD) 30.</p>

<p><strong>RESULTS: </strong>The median age was 44&nbsp;years (IQR 29,58), and 53% were female. The size of the dominant stone was 7.5&nbsp;mm (IQR 5,11), and 50% were located in the kidney. There was consistency among instruments assessing similar concepts. Pain intensity and urinary symptoms increased from baseline to POD 1 with apparent peaks in the first 2&nbsp;days, remained elevated with stent in situ, and varied widely among individuals. Interference due to pain, and bother due to urinary symptoms, likewise demonstrated high individual variability.</p>

<p><strong>CONCLUSIONS: </strong>This first study investigating daily SAS allows for a more in-depth look at the lived experience after URS and the impact on quality of life. Different instruments measuring pain intensity, pain interference, and urinary symptoms produced consistent assessments of patients' experiences. The overall daily stability of pain and urinary symptoms after URS was also marked by high patient-level variation, suggesting an opportunity to identify characteristics associated with severe SAS after URS.</p>

DOI

10.1186/s12894-022-01004-9

Alternate Title

BMC Urol

PMID

35387623

Title

Prevention of Urinary Stones With Hydration (PUSH): Design and Rationale of a Clinical Trial.

Year of Publication

2020

Date Published

2020 Nov 16

ISSN Number

1523-6838

Abstract

<p><strong>RATIONALE &amp; OBJECTIVE: </strong>Although maintaining high fluid intake is an effective, low-risk intervention for the secondary prevention of urinary stone disease (USD), many stone patients do not increase their fluid intake.</p>

<p><strong>STUDY DESIGN: </strong>We describe the rationale and design of the Prevention of Urinary Stones with Hydration (PUSH) study, a randomized trial of a multi-component behavioral intervention program to increase and maintain high fluid intake. Participants are randomized (1:1 ratio) to intervention or control arm. The target sample size is 1642 participants.</p>

<p><strong>SETTING &amp; PARTICIPANTS: </strong>Adults and adolescents ≥12 years of age with a symptomatic stone history and low urine volume are eligible. Exclusion criteria include infectious or monogenic causes of USD and comorbid conditions precluding increased fluid intake.</p>

<p><strong>INTERVENTIONS: </strong>All participants receive usual care and a smart water bottle and smartphone application. Participants in the intervention arm receive a fluid intake prescription and an adaptive program of behavioral interventions, including financial incentives, structured problem solving, and other automated adherence interventions. Control arm participants receive guideline-based fluid instructions.</p>

<p><strong>OUTCOMES: </strong>The primary endpoint is recurrence of a symptomatic stone over 24-months of follow-up. Secondary endpoints include changes in radiographic stone burden, 24-hour urine output, and urinary symptoms.</p>

<p><strong>LIMITATIONS: </strong>Periodic 24-hour urine volumes may not fully reflect daily behavior.</p>

<p><strong>CONCLUSIONS: </strong>With its highly novel features, the PUSH study will address an important healthcare problem.</p>

DOI

10.1053/j.ajkd.2020.09.016

Alternate Title

Am J Kidney Dis

PMID

33212205

Title

Study to Enhance Understanding of Stent-Associated Symptoms: Rationale and Study Design.

Year of Publication

2020

Date Published

2020 Nov 16

ISSN Number

1557-900X

Abstract

<p>Ureteral stents are commonly employed after ureteroscopy to treat urinary stone disease, but the devices impose a substantial burden of stent-associated symptoms (SAS), including pain and urinary side effects. The NIDDK (National Institute of Diabetes and Digestive and Kidney Diseases) Urinary Stone Disease Research Network sought to develop greater understanding of SAS causes and severity among individuals treated ureteroscopically for ureteral or renal stones. We designed a prospective, observational cohort study comprising adolescents and adults undergoing ureteroscopic intervention for ureteral or renal stones. Participants will undergo detailed symptom assessment using validated questionnaires, a psychosocial assessment, and detailed collection of clinical and operative data. Quantitative sensory testing will be utilized to assess pain sensitization. In addition, a small cohort (∼40 individuals) will participate in semi-structured interviews to develop more granular information regarding their stent symptoms and experience. Biospecimens (blood and urine) will be collected for future research. The Study to Enhance Understanding of sTent-associated Symptoms (STENTS) enrolled its first participant in March 2019 and completed nested qualitative cohort follow-up in August 2019. After a planned pause, enrollment for the main study cohort resumed in September 2019 and is expected to be completed in 2021. STENTS is expected to provide important insights into the mechanisms and risk factors for severe ureteral SAS after ureteroscopy. These insights will generate future investigations to mitigate the burden of SAS among individuals with urinary stone disease.</p>

DOI

10.1089/end.2020.0776

Alternate Title

J Endourol

PMID

33081503

Title

The Effects of Tacrolimus on T-Cell Proliferation Are Short-Lived: A Pilot Analysis of Immune Function Testing.

Year of Publication

2017

Number of Pages

e199

Date Published

2017 Aug

ISSN Number

2373-8731

Abstract

<p><strong>BACKGROUND: </strong>Optimal immunosuppression after organ transplant should balance the risks of rejection, infection, and malignancy while minimizing barriers to adherence including frequent or time-sensitive dosing. There is currently no reliable immune function assay to directly measure the degree of immunosuppression after transplantation.</p>

<p><strong>METHODS: </strong>We developed an immune function assay to mea//sure T-cell proliferation after exposure to immunosuppression in vivo. We tested the assay in mice, and then piloted the approach using single time point samples, 11 pediatric kidney transplant recipients prescribed tacrolimus, mycophenolate, and prednisone 6 months to 5 years posttransplant, with no history of rejection, opportunistic infection, or cancer. Twelve healthy adults were controls.</p>

<p><strong>RESULTS: </strong>We demonstrated that our assay can quantify suppression of murine T-cell proliferation after tacrolimus treatment in vivo. In humans, we found a mean 25% reduction in CD4 and CD8 T-cell proliferation in pediatric renal transplant recipients on triple immunosuppression compared with adult healthy controls, but the pilot results were not statistically significant nor correlated with serum tacrolimus levels. We observed that cell processing and washing reduced the effects of tacrolimus on T-cell proliferation, as did discontinuation of tacrolimus treatment shortly before sampling.</p>

<p><strong>CONCLUSIONS: </strong>T-cell proliferation is currently not suitable to measure immunosuppression because sample processing diminishes observable effects. Future immune function testing should focus on fresh samples with minimal washing steps. Our results also emphasize the importance of adherence to immunosuppressive treatment, because T-cell proliferation recovered substantially after even brief discontinuation of tacrolimus.</p>

DOI

10.1097/TXD.0000000000000715

Alternate Title

Transplant Direct

PMID

28795150

Title

Revisiting multi-organ transplantation in the setting of scarcity.

Year of Publication

2014

Number of Pages

21-6

Date Published

2014 Jan

ISSN Number

1600-6143

Abstract

<p>In the setting of organ scarcity, the ethics of multi-organ transplantation (MOT) deserve new examination. MOT offers substantial benefits to certain recipients, including avoiding serial surgeries. However, MOT candidates in the United States commonly receive priority for their nonprimary organ over many individuals who need that organ, which may undermine equity. The absence of standard criteria for MOT eligibility also enables large and unfair regional variation in MOT, such as simultaneous liver-kidney transplantation. Unfortunately, MOT may also undermine utility (optimal patient and graft survival) in circumstances where providing multiple organs to one person fails to achieve the greater collective benefit attained by providing transplants to multiple people. Policy reforms should include the adoption of minimal clinical criteria for MOT candidacy with the attendant goal of decreasing regional variation in MOT. In the future, these minimal criteria can be revised to accommodate new research about which patients derive the most benefit from MOT. Incentives to perform MOT should also be reduced, such as by including MOT outcomes in center-specific reports. These reforms run the risk that the transplant community could be perceived as abandoning MOT candidates, but offer an opportunity to align transplant practice and ethical principles.</p>

DOI

10.1111/ajt.12557

Alternate Title

Am. J. Transplant.

PMID

24354869

Title

Geographic determinants of access to pediatric deceased donor kidney transplantation.

Year of Publication

2014

Number of Pages

827-35

Date Published

2014 Apr

ISSN Number

1533-3450

Abstract

<p>Children receive priority in the allocation of deceased donor kidneys for transplantation in the United States, but because allocation begins locally, geographic differences in population and organ supply may enable variation in pediatric access to transplantation. We assembled a cohort of 3764 individual listings for pediatric kidney transplantation in 2005-2010. For each donor service area, we assigned a category of short (&lt;180 days), medium (181-270 days), or long (&gt;270 days) median waiting time and calculated the ratio of pediatric-quality kidneys to pediatric candidates and the percentage of these kidneys locally diverted to adults. We used multivariable Cox regression analyses to examine the association between donor service area characteristics and time to deceased donor kidney transplantation. The Kaplan-Meier estimate of median waiting time to transplantation was 284 days (95% confidence interval, 263 to 300 days) and varied from 14 to 1313 days across donor service areas. Overall, 29% of pediatric-quality kidneys were locally diverted to adults. Compared with areas with short waiting times, areas with long waiting times had a lower ratio of pediatric-quality kidneys to candidates (3.1 versus 5.9; P&lt;0.001) and more diversions to adults (31% versus 27%; P&lt;0.001). In multivariable regression, a lower kidney to candidate ratio remained associated with longer waiting time (hazard ratio, 0.56 for areas with &lt;2:1 versus reference areas with ≥5:1 kidneys/candidates; P&lt;0.01). Large geographic variation in waiting time for pediatric deceased donor kidney transplantation exists and is highly associated with local supply and demand factors. Future organ allocation policy should address this geographic inequity.</p>

DOI

10.1681/ASN.2013070684

Alternate Title

J. Am. Soc. Nephrol.

PMID

24436470

Title

Outcomes Among Children Who Received a Kidney Transplant in the United States From a Hepatitis B Core Antibody-Positive Donor, 1995-2010.

Year of Publication

2015

Date Published

2015 Oct 14

ISSN Number

2048-7207

Abstract

<p><strong>BACKGROUND: </strong>Accepting kidneys for transplant from donors with a history of hepatitis B virus infection may increase the availability of organs for those with end-stage kidney disease. In adult recipients, kidney transplants from hepatitis B virus core antibody-positive donors have resulted in favorable graft and patient survival rates. However, pediatric organ transplant recipients have developing immune systems and a higher risk of infectious complications than adults. Accordingly, little is known about the outcomes of children who have received a kidney transplant from a hepatitis B virus core antibody-positive donor.</p>

<p><strong>METHODS: </strong>We included 11 898 children ≤18 years of age who received a first kidney transplant in the United States between January 1, 1995, and December 31, 2010, and who were recorded in the Scientific Registry of Transplant Recipients. We examined differences in graft and patient survival rates among children who received a kidney transplant from a hepatitis B virus core antibody-positive donor.</p>

<p><strong>RESULTS: </strong>There were 199 children (1.7%) who received a kidney transplant from a hepatitis B virus core antibody-positive donor. More than 80% of these transplants occurred in recipients who were hepatitis B virus core antibody and surface antigen negative. After a median follow-up of 7.9 years, there were no significant differences in the adjusted graft (hazard ratio [HR], 1.03 [95% confidence interval (CI), 0.80-1.31]) or patient (HR, 1.12 [95% CI, 0.73-1.73]) survival rates according to donor core antibody status.</p>

<p><strong>CONCLUSIONS: </strong>It may be acceptable, on a case-by-case basis, to consider hepatitis B virus core antibody-positive donors for kidney transplants to seroprotected children with end-stage kidney disease.</p>

DOI

10.1093/jpids/piv070

Alternate Title

J Pediatric Infect Dis Soc

PMID

26501473

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