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Background: Cardiovascular (CV) morbidity after kidney transplantation (KTx) in childhood is of increasing importance. In light of a high prevalence of CV risk factors, protective measures such as physical activity (PA) come into focus. Our aim was to comprehensively assess PA in pediatric KTx recipients and evaluate its impact on CV health., Methods: Forty-eight patients were assessed for frequency, duration, intensity, and setting of PA using the "Motorik-Modul" PA questionnaire. Walking-based activity was measured by accelerometer in a subgroup (n = 23). CV risk factors and subclinical CV organ damage were determined. The impact of PA on CV parameters was analyzed using linear regression models., Results: Fifty-two percent of pediatric KTx recipients did not reach WHO recommended PA level; 54% did not engage in PA with vigorous intensity (VPA). Twenty-nine percent indicated an extremely inactive lifestyle (< 120 min/week of moderate to vigorous intensity PA, MVPA). Compared to the healthy German KiGGS cohort, KTx recipients specifically lacked engagement in sport activities (KTx: 129 min/week; 95%CI, 97-162 vs. KiGGS, 242 min/week; 95%CI, 230-253). VPA was associated with lower systolic blood pressure (p = 0.024) and resting heart rate (p = 0.005), MVPA with fewer components of the post-transplant metabolic syndrome (p = 0.037), and better left ventricular diastolic function (p = 0.006)., Conclusions: A considerable lack of PA, especially VPA, exists in young KTx recipients. PA was positively associated with important parameters of CV health. While long-term CV protection through PA seems promising in pediatric KTx recipients, specific educational approaches are most likely needed to increase patients' engagement in sport activities., (© 2023. The Author(s).)

In patients after kidney transplantation (KTx) an increased rate of affective and anxiety disorders has been observed. Repeatedly, a relationship between mental health issues and increased morbidity and mortality in KTx recipients has been reported. However, information on the prevalence of mental disorders in KTx patients is scarce. As part of the structured multimodal follow-up program (KTx360°), mental disorders were examined in 726 patients after KTx through structured diagnostic interviews using the Mini-DIPS Open Access. Overall, 27.5% had a current and 49.2% a lifetime mental disorder. Only 14.5% with a current mental disorder reported to be in treatment. Affected patients were younger, more often female, reported more symptoms of anxiety and depression and less perceived social support. While comparable to the rate in general population samples, the prevalence of mental disorders should attract attention. The low treatment rate requires an improved identification of afflicted patients and provision of specialist treatment.ISRCTN registry, https://doi.org/10.1186/ISRCTN29416382 , date of registry: 03.05.2017., (© 2022. The Author(s).)

Mortality in children with kidney failure is higher in girls than boys with cardiovascular complications representing the most common causes of death. Pulse wave velocity (PWV), a measure of vascular stiffness, predicts cardiovascular mortality in adults. Here, PWV in children with kidney failure undergoing kidney replacement therapy was investigated to determine sex differences and potential contributing factors. Two-hundred thirty-five children (80 girls; 34%) undergoing transplantation (150 pre-emptive, 85 with prior dialysis) having at least one PWV measurement pre- and/or post-transplantation from a prospective cohort were analyzed. Longitudinal analyses (median/maximum follow-up time of 6/9 years) were performed for PWV z-scores (PWVz) using linear mixed regression models and further stratified by the categories of time: pre-kidney replacement therapy and post-transplantation. PWVz significantly increased by 0.094 per year and was significantly higher in girls (PWVz +0.295) compared to boys, independent of the underlying kidney disease. During pre-kidney replacement therapy, an average estimated GFR decline of 4 ml/min/1.73 m 2 per year was associated with a PWVz increase of 0.16 in girls only. Higher diastolic blood pressure and low density lipoprotein were independently associated with higher PWVz during pre-kidney replacement therapy in both sexes. In girls post-transplantation, an estimated GFR decline of 4ml/min/1.73m 2 per year pre-kidney replacement therapy and a longer time (over 12 months) to transplantation were significantly associated with higher PWVz of 0.22 and of 0.57, respectively. PWVz increased further after transplantation and was positively associated with time on dialysis and diastolic blood pressure in both sexes. Thus, our findings demonstrate that girls with advanced chronic kidney disease are more susceptible to develop vascular stiffening compared to boys, this difference persist after transplantation and might contribute to higher mortality rates seen in girls with kidney failure., (Copyright © 2021 International Society of Nephrology. Published by Elsevier Inc. All rights reserved.)

Objective: Organ transplantation is the treatment of choice for patients with end-stage organ disease. From early on, the psychological perspective on integrating the organ has been of interest. As quantitative studies on organ integration are scarce, we aimed at evaluating this aspect in a large sample of kidney transplant (KTx) recipients., Methods: For this cross-sectional study, 684 patients after KTx were recruited within the structured post-transplant care program KTx360°. To measure organ integration and donor relationship, a previously developed and published questionnaire (FOSP), generated explicitly for this purpose, was used. Associations with sociodemographic, medical, donation-specific, and psychological variables were investigated., Results: Overall, more than 90% of the patients perceived the transplant as part of themselves; however, a small minority reported perceiving it as a foreign object. Frequent thoughts about the donor and the belief of having adopted some of the donor's traits were common (52% and 14%, respectively), specifically in living donor recipients. Higher anxiety and depression scores and reduced kidney functioning were associated with less ideal organ integration, while a more extended period since KTx and more perceived social support correlated with better organ integration. No association between organ integration and adherence, as well as organ integration and cognitive functioning, could be found., Conclusion: Organ integration and donor relationship were unproblematic in most KTx patients. However, offering psychosocial support to those struggling with organ integration and donor relationship is crucial from a clinical perspective., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to declare., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Guidelines recommend a healthy lifestyle and regularly physical activity (PA) after kidney transplantation (KTx). The KTx360° program is a multicenter, multisectoral, multimodal, telemedicine-based follow-up care program. Effects of the first COVID-19 wave restrictions on health-related quality of life and PA of supervised KTx360° patients were evaluated using an online questionnaire. Six hundred and fifty-two KTx360° patients were contacted via email and were asked to complete the Freiburg questionnaire of physical activity and the Short form 12 Health Survey (SF-12) online. Pre-pandemic and lockdown data were compared in 248 data sets. While sporting activity decreased during the COVID-19 pandemic, basic and leisure activity increased, resulting in increased overall activity. The physical component scale of the SF-12 was in the low normal range before as well as during the pandemic, with a small but significant increase during the pandemic. The mental component scale showed normal values before and during pandemic with a small but statistically significant decrease. Our study supports the effectiveness of a telemedicine based program for KTx patient care in maintaining PA and quality of life during the first peak of the COVID-19 pandemic. However, further research and observation during the ongoing pandemic are required., Competing Interests: The authors declare no conflict of interest.

Objective: A common reason for organ rejection after transplantation is the lack of adherence regarding immunosuppressive medication (ISM). A variety of different aspects can promote non-adherent behavior, including the relationship between perceived benefits and concerns regarding ISM ("necessity-concerns-framework"). Little is known about the variables associated with this framework., Methods: As part of this cross-sectional study, 570 patients after kidney transplantation who participated in a structured multimodal follow-up program (KTx360°) were examined in two transplant centers in Lower Saxony. We used the Beliefs about Medicines Questionnaire (BMQ) to evaluate the patients' believes and concerns regarding their ISM., Results: The mean age of the participants was 51.9 (SD 14.17) years, 58.4% were men, and 25.8% had ≥12 years of school attendance. The mean time since transplantation was 65.9 months. In patients undergoing kidney transplantation, the perceived benefit of ISM mostly exceeded the concerns. We found an association between lower perceived benefits and greater concerns and lower adherence. Also, a higher perceived necessity was significantly associated with higher age and lower levels of depression and anxiety. Greater concerns were significantly associated with more symptoms of depression and anxiety, lower perceived social support, and lower kidney functioning (eGFR)., Conclusion: Even though patients after kidney transplantation usually acknowledge the importance of their ISM, they still have considerable concerns that are associated with less adherence and various psychosocial risk factors. Further longitudinal studies are needed to assess the extent to which beliefs about medication are variable and can be individually addressed to improve adherence., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Follow-up care after kidney transplantation is performed in transplant centers as well as in local nephrologist's practices in Germany. However, organized integrated care of these different sectors of the German health care system is missing. This organizational deficit as well as non-adherence of kidney recipients and longterm cardiovascular complications are major reasons for an impaired patient and graft survival., Methods: The KTx360° study is supported by a grant from the Federal Joint Committee of the Federal Republic of Germany. The study will include 448 (39 children) incident patients of all ages with KTx after study start in May 2017 and 963 (83 children) prevalent patients with KTx between 2010 and 2016. The collaboration between transplant centers and nephrologists in private local practices will be supported by internet-based case-files and scheduled virtual visits (patient consultation via video conferencing). At specified points of the care process patients will receive cardiovascular and adherence assessments and respective interventions. Care will be coordinated by an additional case management. The goals of the study will be evaluated by an independent institute using claims data from the statutory health insurances and data collected from patients and their caregivers during study participation. To model longitudinal changes after transplantation and differences in changes and levels of immunosuppresive therapy after transplantation between study participants and historical data as well as data from control patients who do not participate in KTx360°, adjusted regression analyses, such as mixed models with repeated measures, will be used. Relevant confounders will be controlled in all analyses., Discussion: The study aims to prolong patient and graft survival, to reduce avoidable hospitalizations, co-morbidities and health care costs, and to enhance quality of life of patients after kidney transplantation., Trial Registration: ISRCTN29416382 (retrospectively registered on 05.05.2017).

Sophie de Boer,1,2 Felix Klewitz,1,2 Maximilian Bauer-Hohmann,1,2 Lena Schiffer,2,3 Uwe Tegtbur,2,4 Lars Pape,2,3 Mario Schiffer,2,5,6 Martina de Zwaan,1,2 Mariel Nöhre1,2 1Department of Psychosomatic Medicine and Psychotherapy, Hannover Medical School, Hannover, Germany; 2Project Kidney Transplantation 360° (NTx360°), Hannover Medical School, Hannover, Germany; 3Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany; 4Department of Sports Medicine, Hannover Medical School, Hannover, Germany; 5Department of Nephrology and Hypertension, University Hospital Erlangen, Erlangen, Germany; 6Department of Nephrology and Hypertension, Hannover Medical School, Hannover, GermanyCorrespondence: Mariel Nöhre Department of Psychosomatic Medicine and PsychotherapyHannover Medical School, Carl-Neuberg-Strasse 1, Hannover 30625, GermanyTel +49 511 532 3932Fax +49 511 532 3190Email noehre.mariel@mh-hannover.dePurpose: After organ transplantation, adherence to immunosuppressive medication (ISM) is crucial to prevent organ rejection. To enable adherence, patients need to be well informed about the different aspects associated with their ISM. However, literature suggests that knowledge regarding ISM is often inadequate.Patients and Methods: In a cross-sectional study, 702 patients after kidney transplantation participating in a structured multimodal follow-up program (KTx360°) were evaluated. We utilized a self-developed questionnaire which has been successfully used before to measure patients’ knowledge about the ISM. Above that we aimed to evaluate potential associations between sociodemographic, medical, donation-specific, and psychosocial variables including adherence, levels of depression and anxiety, perceived social support, and cognitive functioning with the knowledge level.Results: The mean age of the patients was 52.4 years, 58.1% were men, and 66.6% were living in a partnership. The mean time since transplantation was 65.1 months. On average, patients answered 70.9% of the questions correctly. The percentage of correct answers per question differed considerably (54%– 92%). In univariate analyses, knowledge levels were positively associated with female gender, current partnership, German as first language and better cognitive functioning. However, the effect sizes were small.Conclusion: Taking into account that the patients after KTx can be expected to answer all questions correctly as they aim at basic knowledge, an average result of 70.9% corresponds to a moderate knowledge level. Consequently, the current educational approaches do not seem to be sufficient to inform all patients adequately. Further research is necessary on how to improve health knowledge in the long term.Keywords: health literacy, kidney transplantation, renal transplantation, adherence, immunosuppressive medication