American Journal of Transplantation 2011; 11: 2264–2265 Wiley Periodicals Inc.

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Copyright 2011 The American Society of Transplantation and the American Society of Transplant Surgeons doi: 10.1111/j.1600-6143.2011.03713.x

Letter to the Editor

Improving Long-Term Outcomes for Transplant Patients: Making the Case for Long-Term Disease-Specific and Multidisciplinary Research
To the Editor: We thank Dr. De Geest and coauthors for their letter corresponding to our paper and certainly agree to the principles they outlined (1). Improvements in posttransplant outcomes are often defined by discrete quantifiable variables such as rejection rates and 1-year survival. Characterizing aspects of transplantation such as quality of life, overall cost of care and long-term survival require longer follow-up and detailed tracking of numerous variables. Although we can describe relative success in the short-term, the longer term and more complex areas of needed improvement are limited by our capacity to track and identify specific areas of intervention. The longer the posttransplant phase grows, the more intricate the interplay of chronic disease, immunosuppression and socioeconomic risk becomes. Indeed, patient self-management in chronic illness is not only important, but a requirement to ensure optimal health outcomes. Management of chronic conditions has long been a challenging area to track given the need for longer follow-up times in large and heterogeneous populations (2). Additionally, the ability to identify risk factors for poor health outcomes in an aging population requires development of stratification models that account for the accumulation of additional health conditions and interventions over time. Encouraging patient self-management must be accompanied by a vigorous effort to track outcomes and identify specific areas of intervention that we can then translate to patient-directed care. These efforts are, in part, limited by our current lack of a centralized patient tracking ability over a long period of time. While we have broad observational data available via national registry data to some extent, we are confined to local center data in order to track detailed patient-level outcomes relative to specific therapeutic and interventional strategies. We are also becoming increasingly aware of the impact of socioeconomic conditions that limit patient follow-up and preventive care (3). Identifying at-risk populations in the pretransplant phase and directing efforts and reimbursement to supportive programs may prevent future complications. Nearly half of kidney transplant recipients are unaware that Medicare coverage will end at 36 months (4). Financial burdens on transplant recipients result in devastating and frustratingly preventable losses of both graft and life. Redirecting finances to provide maximum maintenance of the allograft should be a major focus of our evolving health policy to ensure both improved medical outcomes and cost-effective care. Racial disparities noted in long-term survival rates (5) will require an approach that addresses both biological and socioeconomic factors. As the current generation of transplant recipients continues to age, we are now faced with the sequelae of various immunosuppressive strategies (6) intermingled with the lasting effects of chronic disease states in the setting of the ever-increasing health care cost burden. Strategies to dissect out specific risk factors and targets of intervention will require first and foremost a dedicated system to monitor and capture clinically significant data. A continued multidisciplinary and appropriate analytic approach will be needed to evaluate how addressing one disease variable may affect other disease states in the same patient. Similarly, many of our current standard-of-care practices in chronic disease states have yet to be validated in transplant recipients. Patient self-management can become a cornerstone of long-term management once we have the tools to adequately guide the patient into the posttransplant phase. Advancing the next era of long-term improvement will require extrapolating the same efforts that led to dramatic short-term improvements into the future. S. A. Lodhi a , K. E. Lambb and H.-U. Meier-Krieschec a Emory University, Atlanta, GA b Chronic Disease Research Group, Minneapolis, MN c University of Florida, Gainesville, FL

Disclosure
The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.

References
1. De Geest S, Dobbels F, Gordon E, De Simone P. Chronic illness management as an innovative pathway for enhancing long-term survival in transplantation. Am J Transplant 2011; 11: 2262–2263. 2. Tinetti ME, Studenski SA. Comparative effectiveness research and patients with multiple chronic conditions. N Engl J Med 2011; Epub ahead of print.

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4. Lamb KE. Meier-Kriesche HU. Gordon EJ. Prohaska TR. Hinrichsen VL. 170: 1918–1925. Arch Intern Med 2010.Letter to the Editor 3. 6. Meier-Kriesche HU. 11: 450–462. Kullgren JT. Clin J Am Soc Nephrol 2008. 3(Suppl 2): S101–S116. an alternative approach to reducing side effects: Objectives and interim result. Minimizing immunosuppression. Lodhi S. American Journal of Transplantation 2011. 22: 738–748. 11: 2264–2265 2265 . 5. Sehgal AR. Long-term renal allograft survival in the United States: A critical reappraisal. The financial impact of immunosuppressant expenses on new kidney transplant recipients. et al. Srinivas TR. Galbraith AA. Clin Transplant 2008. Am J Transplant 2011. Health care use and decision making among lower-income families in high-deductible health plans.