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      Work Ability and Labor Supply after Kidney Transplantation

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          Background: The vocational rehabilitation after kidney transplantation (KTX) is suboptimal. We sought to evaluate correlates of occupational outcomes after KTX. Methods: We included 336 working-age patients with at least one creatinine assessment in the 3-month screening period. We collected clinical information from medical records. All subjects answered a self-administered questionnaire, and a follow-up questionnaire was mailed to each participant after 6 months. Study outcomes were the Work Ability Index (WAI) and labor supply (the number of days each patient worked in the follow-up period). We estimated the glomerular filtration rate (eGFR) with the Modification of Diet in Renal Disease Study equation. Results: The mean eGFR was 52.76 ± 23.68 ml/min/1.73 m<sup>2</sup>. The age-standardized employment-to-population ratio was 62%. Comorbidities, self-reported work ability, gender, age, health insurance type, and time since transplant were associated with employment status at baseline. The WAI (38.79 ± 5.88) was associated with the severity of renal impairment, work attachment and comorbidities. After 6 months, labor supply (mean 19.4 ± 9.7 weeks) was associated with WAI item 1 (ρ = 0.22; p = 0.03); eGFR was significantly associated with labor supply, and this association was slightly stronger in patients with physically demanding jobs. Conclusions: We identified modifiable factors associated with poor occupational outcomes in kidney transplant recipients. Consistent with labor supply theory, our results suggest that health care coverage plays a key role in employment decisions after KTX independent of possible confounders. Additionally, our study provides the rationale to further evaluate the implications of renal function-preserving strategies for indirect cost savings and self-reported ability to work after transplant.

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          Most cited references 24

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          The natural history of chronic allograft nephropathy.

          With improved immunosuppression and early allograft survival, chronic allograft nephropathy has become the dominant cause of kidney-transplant failure. We evaluated the natural history of chronic allograft nephropathy in a prospective study of 120 recipients with type 1 diabetes, all but 1 of whom had received kidney-pancreas transplants. We obtained 961 kidney-transplant-biopsy specimens taken regularly from the time of transplantation to 10 years thereafter. Two distinctive phases of injury were evident as chronic allograft nephropathy evolved. An initial phase of early tubulointerstitial damage from ischemic injury (P<0.05), prior severe rejection (P<0.01), and subclinical rejection (P<0.01) predicted mild disease by one year, which was present in 94.2 percent of patients. Early subclinical rejection was common (affecting 45.7 percent of biopsy specimens at three months), and the risk was increased by the occurrence of a prior episode of severe rejection and reduced by tacrolimus and mycophenolate therapy (both P<0.05) and gradually abated after one year. Both subclinical rejection and chronic rejection were associated with increased tubulointerstitial damage (P<0.01). Beyond one year, a later phase of chronic allograft nephropathy was characterized by microvascular and glomerular injury. Chronic rejection (defined as persistent subclinical rejection for two years or longer) was uncommon (5.8 percent). Progressive high-grade arteriolar hyalinosis with luminal narrowing, increasing glomerulosclerosis, and additional tubulointerstitial damage was accompanied by the use of calcineurin inhibitors. Nephrotoxicity, implicated in late ongoing injury, was almost universal at 10 years, even in grafts with excellent early histologic findings. By 10 years, severe chronic allograft nephropathy was present in 58.4 percent of patients, with sclerosis in 37.3 percent of glomeruli. Tubulointerstitial and glomerular damage, once established, was irreversible, resulting in declining renal function and graft failure. Chronic allograft nephropathy represents cumulative and incremental damage to nephrons from time-dependent immunologic and nonimmunologic causes. Copyright 2003 Massachusetts Medical Society
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            Determinants of work ability and its predictive value for disability.

            Maintaining the ability of workers to cope with physical and psychosocial demands at work becomes increasingly important in prolonging working life. To analyse the effects of work-related factors and individual characteristics on work ability and to determine the predictive value of work ability on receiving a work-related disability pension. A longitudinal study was conducted among 850 construction workers aged 40 years and older, with average follow-up period of 23 months. Disability was defined as receiving a disability pension, granted to workers unable to continue working in their regular job. Work ability was assessed using the work ability index (WAI). Associations between work-related factors and individual characteristics with work ability at baseline were evaluated using linear regression analysis, and Cox regression analysis was used to evaluate the predictive value of work ability for disability. Work-related factors were associated with a lower work ability at baseline, but had little prognostic value for disability during follow-up. The hazard ratios for disability among workers with a moderate and poor work ability at baseline were 8 and 32, respectively. All separate scales in the WAI had predictive power for future disability with the highest influence of current work ability in relation to job demands and lowest influence of diseases diagnosed by a physician. A moderate or poor work ability was highly predictive for receiving a disability pension. Preventive measures should facilitate a good balance between work performance and health in order to prevent quitting labour participation.
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              Cardiovascular toxicities of immunosuppressive agents.

               L. Miller (2002)
              Cardiovascular disease is one of the major causes of morbidity and mortality following solid organ transplantation. Many of the current immunosuppressive drugs are associated with an increase of one or more risk factors for the development of atherosclerosis. This review compares the mechanism by which individual immunosuppressive agents may impact on these risk factors and the differential contribution of cyclosporine, tacrolimus, mycophenolate, azathioprine, and Rapamycin to these individual risk factors. Attention to the potential cardiovascular toxicities of individual immunosuppressive agents may help design strategies for maintenance of immunosuppression tailored to individual patients.

                Author and article information

                Am J Nephrol
                American Journal of Nephrology
                S. Karger AG
                November 2014
                25 October 2014
                : 40
                : 4
                : 353-361
                aDipartimento di Scienze Cliniche e di Comunità, Università di Milano, and bClinica del Lavoro Luigi Devoto, Fondazione IRCCS ‘Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy; cDivision of Clinical Research, Department of Obstetrics and Gynecology; dDivision of Infectious Diseases, Department of Internal Medicine, Washington University School of Medicine, and eCenter for Outcomes Research, Saint Louis University, St. Louis, Mo., USA
                Author notes
                *Luca Neri, MD, PhD, Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi di Milano, Fondazione IRCCS ‘Ca' Granda, Ospedale Maggiore Policlinico, Clinica del Lavoro Luigi Devoto, Via San Barnaba 8, IT-20122 Milano (Italy), E-Mail luca.neri@unimi.it
                365155 Am J Nephrol 2014;40:353-361
                © 2014 S. Karger AG, Basel

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                Page count
                Figures: 2, Tables: 3, Pages: 9
                Original Report: Transplantation


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