Renal Transplantation and Renovascular Hypertension Re: Urological Nephrectomies for Benign Disease: A Possible Missed Resource in Organ Donation

available at http://www.ncbi. nlm.nih. gov/pubmed/30084762 Editorial Comment: The authors describe 3 cases of use of a kidney with benign disease, typically resulting in a significant pain syndrome, where all options for repair had been exhausted and the individuals opted for removal of the organ as opposed to autotransplant. In this setting the organs were removed and used for live donor kidney transplantation. This process is similar in concept to the use of kidneys with small renal masses. The cases included donors with nephrostomy dependent ureteropelvic junction obstruction, loin pain hematuria syndrome and an autotransplanted kidney with chronic pain. All 3 cases yielded demonstrable pain relief benefit for the donor, and the transplants were successful. Importantly the authors emphasize to patients the importance of renal preservation before consideration of organ removal. Only after all options are exhausted and patients independently choose nephrectomy is it permissible to discuss donation. This is the only way this practice can be supported ethically. The authors were cautious in their approach to avoid “advocating for comfort nephrectomies or coercing patients. ” These are all uncommon case scenarios. However, if handled appropriately, they may be suitable for organ donation. David A. Goldfarb, MD Re: Outcomes for Individuals Turned Down for Living Kidney Donation P. P. Reese, M. B. Allen, C. Carney, D. Leidy, S. Levsky, R. Pendse, A. S. Mussell, F. Bermudez, S. Keddem, C. Thiessen, J. R. Rodrigue and E. J. Emanuel Department of Biostatistics and Epidemiology, Renal Division, and Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Center for Health Incentives and Behavioral Economics, Leonard Davis Institute, School of Arts and Sciences, University of Pennsylvania and Crescenz Veterans Affairs Medical Center, Center for Evaluation of the Patient Aligned Care Team, Philadelphia, Pennsylvania, Department of Medicine, Brigham and Women’s Hospital, and Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, Princeton University, Princeton, New Jersey, and Department of Surgery, Yale University School of Medicine, New Haven, Connecticut Clin Transplant 2018; 32: e13408. doi: 10.1111/ctr.13408 Abstract available at http://www.ncbi. nlm.nih. gov/pubmed/30218994available at http://www.ncbi. nlm.nih. gov/pubmed/30218994 Editorial Comment: When a living donor is turned down by selection committee, it is because the risks associated with donation cannot justify proceeding. Donor nephrectomy is not an operation needed for the health of the donor, but rather an altruistic act to enhance the life of a patient with end-stage renal disease. While some risk is inevitable and acceptable, transplant centers must always ensure donor safety and turn down patients with excessive risk. Although certain adverse medical outcomes may be avoided by this decision, there may be undesirable nonmedical consequences. This exploratory study examines the nonmedical outcomes after turndown using surveys and qualitative interviews. A third of turned down donors assessed their life as worse following the 20 RENAL TRANSPLANTATION AND RENOVASCULAR HYPERTENSION Copyright © 2019 American Urological Association Education and Research, Inc. Unauthorized reproduction of this article is prohibited. decision compared to 7% of qualified donors. In the cohort of turned down donors with worse quality of life 77% had an intended recipient who never received a transplant. Being turned down as a donor can have significant emotional impact. The relationship to the recipient was an important way these patients processed the experience. Those performing donor evaluations may want to consider disclosing the risk of adverse consequences of a turndown early in the evaluation process. David A. Goldfarb, MD Socioeconomic Factors, Urological Epidemiology and Practice Patterns Re: Interpersonal and Organizational Dynamics are Key Drivers of Failure to Rescue M. E. Smith, E. E. Wells, C. R. Friese, S. L. Krein and A. A. Ghaferi Departments of Surgery and Internal Medicine, University of Michigan Medical School, University of Michigan School of Nursing, Department of Health Management and Policy, University of Michigan School of Public Health, Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System and University of Michigan Stephen M. Ross School of Business, Ann Arbor, Michigan Health Aff (Millwood) 2018; 37: 1870e1876. doi: 10.1377/hlthaff.2018. 0704 Abstract available at http://www.ncbi. nlm.nih. gov/pubmed/30395494available at http://www.ncbi. nlm.nih. gov/pubmed/30395494 Editorial Comment: Failure to rescue refers to mortality following a major postoperative complication, and has been implicated as a major driver of variation in surgical outcomes. While there is rich literature surrounding variation in rates of failure to rescue, few studies have “looked under the hood” to identify modifiable organizational factors associated with rescue. These investigators conducted structured interviews with hospitals participating in the Michigan Surgical Quality Collaborative found to have high and low rates of failure to rescue. Subsequently they coded interviews to identify themes portending performance with respect to rescue. The study identified 5 key areas associated with rescue in the postoperative setting: teamwork, action taking, psychological safety, recognition and communication. Certainly the need for a collaborative, team based approach predicated on effective communication is a necessary component of rescue. The study also found that prompt action after recognition of a complication was associated with more favorable performance. Interestingly hospitals associated with high rates of rescue harbored cultures of safety, with “providers feeling comfortable speaking up, questioning others, reporting mistakes and crossing clinical hierarchies to express concerns. ” This qualitative study identifies numerous modifiable organizational attributes associated with ability to rescue patients from major complications following surgery. The concept of rescue is a critically important one that maps directly to rates of postoperative mortality. As such, efforts to optimize performance with regard to rescue will undoubtedly improve surgical outcomes. This study serves as a roadmap for the surgical ecosystem to develop and implement processes oriented around the prompt recognition of surgical complications, effective team based communication and a culture of safety promoting the fundamental tenets of continuous improvement. As the captains of our respective ships, it is our responsibility to weave these lessons into the fabric of our daily work. In doing so we will unquestionably improve patient outcomes. Matthew J. Resnick, MD, MPH, MMHC Reference 1. Ghaferi AA, Birkmeyer JD and Dimick JB: Variation in hospital mortality associated with inpatient surgery. N Engl J Med 2009; 361: 1368. SOCIOECONOMIC FACTORS, UROLOGICAL EPIDEMIOLOGY AND PRACTICE PATTERNS 21 Copyright © 2019 American Urological Association Education and Research, Inc. Unauthorized reproduction of this article is prohibited.