Background Given the complexity of solid organ transplant recipients, a multidisciplinary approach is required. To promote medication safety and enable providers to focus on the medical and surgical needs of these patients, our department of pharmacy created a collaborative practice agreement between physicians and pharmacists. Through this agreement, credentialed pharmacists are empowered to provide inpatient services including initiation and adjustment of medications through independent review of laboratory results after multidisciplinary rounds. Objective To evaluate the effect of our collaborative practice agreement on clinical care and institutional finances. Setting An inpatient setting at a large academic medical center. Methods Three transplant pharmacists entered all clinical interventions made on abdominal transplant recipients between September and October 2013 into Quantifi, a software application that categorizes and assigns a cost savings value based on impact and type of intervention. Main outcome measure The main outcome measures in this study were number and categorization of interventions, as well as estimated cost savings to the institution. Results There were 1060 interventions recorded, an average of 20 interventions per pharmacist per day. The most common interventions were pharmacokinetic evaluations (36%) and dose adjustments (19%). Over the time period, these interventions translated into an estimated savings of $107,634.00, or an annual cost savings of $373,131.20 per pharmacist, or a cost-benefit ratio of 2.65 to the institution. Conclusions Based on our study, implementation of a collaborative practice agreement enables credentialed pharmacists to make clinically and financially meaningful interventions in a complex patient population.

Panniculectomy can be performed as a prophylactic procedure preceding transplantation to enable obese patients to meet criteria for renal transplantation. No literature exists on combined renal transplant and panniculectomy surgery (LRT‐PAN). We describe our 8‐year experience performing LRT‐PAN. A retrospective chart review of all patients who had undergone LRT‐PAN from 2010 to 2018 was conducted. Data were collected on patient demographics, allograft survival and function, and postoperative course. Fifty‐eight patients underwent LRT‐PAN. All grafts survived, with acceptable function at 1 year. Median length of stay was 4 days with a mean operative duration of 363 minutes. The wound complication rate was 24%. Ninety‐day readmission rate was 52%, with medical causes as the most common reason for readmission (45%), followed by wound (32%) and graft‐related complications (23%). Body mass index, diabetes status, and previous immunosuppression did not influence wound complication rate or readmission (P = .7720, P = .0818, and P = .4830, respectively). Combining living donor renal transplant and panniculectomy using a multidisciplinary team may improve access to transplantation, particularly for the obese and postobese population. This combined approach yielded shorter‐than‐expected hospital stays and similar wound complication rates, and thus should be considered for patients in whom transplantation might otherwise be withheld on the basis of obesity.

Background Recently, it has been shown that panniculectomy concurrent to living donor renal transplantation is a safe option for management of renal transplant recipients with a large focal pannus. This combined management requires precise coordination of teams. We describe the technique, timing, and sequence for combined renal transplantation and panniculectomy. Methods We conducted a retrospective chart review of adult patients (≥18 years old) who underwent simultaneous living donor renal transplantation–panniculectomy from 2015 to 2019. A multi–team approach that included urology, transplant, and plastic surgery was used to perform the combined operations. Typically, the plastic surgery team initiates the operation by performing the panniculectomy. This is followed by kidney transplantation and graft anastomosis. The plastic surgery team then completes the operation with closure of the wound. Results Twenty patients were identified. Most were male (12:8) with a mean age of 55 years and an average body mass index of 35 kg/m2. The mean total operative duration was 394 minutes. On average, 17% of operating time was devoted to panniculectomy. At 90 days follow-up, there was 100% graft survival and all patients had primary graft function. There was a 25% wound complications rate and a 15% reoperation rate. Conclusion By performing panniculectomy first in the sequence, concurrent panniculectomy provides wide exposure and a large operative field for transplantation. Wound closure by plastic surgeons may mitigate the high complication rate commonly seen in obese patients with end-stage renal disease. Future studies are needed to evaluate the cost-benefit of the combined living donor renal transplantation–panniculectomy.

Our study suggests that PI-based antiretroviral therapy regimens are associated with improved graft survival and that patients can achieve adequate outcomes on a PI-based regimen when necessary. Due to study limitations, further studies are needed to determine the optimal immunosuppression/antiretroviral therapy regimen post-transplant.

With escalating life expectancy, elderly patients have become the fastest growing population initiating dialysis. Based on United States Renal Data System (USRDS) estimates, there are over 120 000 people in the United States with end-stage renal disease (ESRD) aged 75 years or older. 1 While this demographic only makes up 6.4% of the entire US population, it accounts for more than 16% of the ESRD population. 2 As elderly patients with kidney disease progress to ESRD and are initiated on dialysis, it is important to understand that dialysis outcomes in this population are often poor. These patients experience a more rapid and profound loss of functional status and quality of life and a higher rate of mortality at one year compared to their younger counterparts. 3 In the United States, the median survival after dialysis initiation is 15.6 months for patients 80-84 years of age and 11.6 months for patients 85-89 years of age. 1 Additionally, with limited dialysis beds and Medicare spending on dialysis exceeding $33 billion annually, the ethics and cost-effectiveness of dialysis in this population needs to be carefully considered. 1 Kidney transplantation, although not without risk, may offer an alternative therapeutic option in the elderly population that can